
Class. 
Book 



COPYRIGHT DEPOSIT 



CLINICAL LECIUKES 



MENTAL DISEASES 



BY 

t's. CLOUSTO]^, M.D.Edin., F.R.C.P.E., 

PHYSICIAN SUPERINTENDENT OF THE ROYAL EDINBURGH ASYLUM FOR THE INSANE ; LECTURER 
ON MENTAL DISEASES IN THE EDINBURGH UNIVERSITY ; FORMERLY CO-EDITOR "JOURNAL 
OF MENTAL SCIENCE ;" FOREIGN ASSOCIATE OF THE SOCIETE MEDICO-PSYCHOLO- 
GIQUE; honorary member op the association OF MEDICAL SUPER- 
INTENDENTS OF AMERICAN INSTITUTIONS FOR THE INSANE, 
AND OF THE NEW ENGLAND PSYCHOLOGICAL SOCIETY. 



TO WHICH IS ADDED 



ABSTRACT OF THE STATUTES OF THE UNITED STATES AND OF 

THE SEVERAL STATES AND TERRITORIES RELATING 

TO THE CUSTODY OF THE INSANE. 



7-' 

CHARLES r. FOLSOM 



M.D. 



FELLOW OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES: ASSISTANT PROFESSOR OF MENTAL 

DISEASES, HARVARD MEDICAL SCHOOL; PHYSICIAN TO OUT-PATIENTS WITH 

DISEASES OP THE NERVOUS SYSTEM, BOSTON CITY HOSPITAL. 

J 




PHILADELPHIA: 

HENRY C. LEA'S SON c^- CO 

1884. 






^■5 



Entered according to Act of Congress, in the year 1884, by 

HENRY C. LEA'S SON & CO., 

in the Office of the Librarian of Congress. All rights reserved. 



DORNAN, PRINTKB. 



AMERICAN PUBLISHER'S PREFACE 



The present work has been so favorably received in England 
that it is only necessary to state that the sheets of the American 
edition, in their passage through the press, have had the super- 
vision of Dr. Charles F. Folsoni, of Boston. To render the 
vvork complete as regards the wants of the American practi- 
tioner, Dr. Folsom, with the assistance of Hollis 11. Bailey, Esq., 
has added an appendix on the laws of the United States, and of 
the several States, relating to the custody of the insane. Prac- 
tice on this point varies so much with local statutes and deci- 
sions that an abstract of this kind would seem to be requisite 
as a guide for the practitioner in the perplexing cases vrhich 
are liable to arise in his practice at any moment. With this 
addition it is hoped that the volume will be found satisfactory 
in all essential points. 

Philadelphia, April, 1884. 



PREFACE TO THE ENGLISH EDITION. 



Another book on Mental Disease almost needs an apology, 
the treatises on the subject of late years having been so 
numerous, and some of them so good. But the subject has 
never yet, in the opinion of many, been treated from so en- 
tirely clinical and practical a point of view as is desired by 
students of medicine, and by busy practitioners. The strong 
point of a clinical lecture should be that it appeals directly 
and on all occasions to the facts of disease as seen in actual 
cases, following the lines of the cases on which it is founded. 
It must have its foundation in the clinical experience of its 
author, this giving it vividness and interest. Its weak points 
are, that the diseases are not treated in a full, systematic, and 
generalized way, that the history of investigation into them 
cannot be entered into, and, therefore, great seeming injustice 
is done to previous authors and investigators. I have been 
much impressed in teaching students by the fact that you can 
manifestly interest every member of a large class when you 
are teaching mental diseases clinically, while you fail to reach 
some of them by systematic descriptions. Direct appeals to 
the facts of nature, however fragmentary, make more im- 
pression on them than any amount of elaborate description. 
These considerations led me to publish the following lectures 
as a text-book for my students in the University of Edin- 
burgh; and I venture to indulge the hope that it will also 



VI PREFACE TO THE ENGLISH EDITION. 

supply a want which I know many busy practitioners of 
medicine feel. The two hundred and sixty cases of mental 
disease which I describe and embody in those lectures may, 
I hope, assist some of my brethren in the profession in their 
treatment of a very obscure and troublesome class of diseases. 
In the selection of those cases, I had in view rather their 
applicability as good, ordinary types and guides than their 
rarity or their striking characters. The tendency in pub- 
lishing mental cases has been to fix on wonderful rather than 
useful examples. 

I have to acknowledge with gratitude the assistance I have 
received from the present or past staff of the Royal Edin- 
burgh Asylum, Drs. Turnbull, Carlyle Johnstone, Mitchell, 
Spence, Steedman, and Harrison Thomas, in getting up the 
statistics of many of the forms of insanity from the records 
of the institution, and especially I have to thank my friend, 
Dr. Ireland, for advice and help in getting the work through 
the press. 



CONTENTS. 



LECTURE I. 
THE CLINICAL STUDY OF MENTAL DISEASES. 

PAGE 

All men students of mind — Medical psycliology — Necessity for medical men 
studjdng mental diseases — Frequency of insanity — Specialism — What 
mental disease implies — The standard of mental health differs — Tempera- 
ments and diatheses — Body and mind — Eeproduction and its mental rela- 
tionships — Clinical mode of studying mental symptoms — Nomenclature of 
mental diseases — Classification by symptoms — Skae's (clinical) classification 
— Some of the most important anatomical, physiological, psychological, and 
pathological considerations to be kept in mind in the clinical study of mental 
diseases — The method of clinically examining an insane patient, and the 
rules to be observed — Home or asylum treatment, . . . . .33 

LECTURE 11. 

STATES OF MENTAL DEPEESSION— MELANCHOLIA {PSYCHALGIA). 

Nearest mental health — Seen at beginning of nearly all kinds of insanity — 
Physiological capacity of feeling — Physiological depression — Melancholic 
phases of existence in all men — The melancholic variety of the nervous 
temperament and diathesis — Influence of heredity — Crises of Life— The 
eight varieties of Melancholia. — Melancholy and melancholia defined. 
Simple Melancholia. — " Low spirits," want of affection, want of interest in 
and enjoyment of life — Fancies, whims, with impairment of reasoning 
power — Not much body wasting — Sometimes goes no further — Often is 
prelude to severe varieties, or to other forms of insanity — Condition comes 
and goes, and depends on slight causes — Curability — Great variety of 
symptoms — Cases A. B. to A. J. Hypochondriacal Melancholia. — Patient's 
depressed feelings centre round himself, and his delusions are about his 
bodily organs and functions — Fancies innumerable in kind and variety — 
Seldom very suicidal — Differences between the sane and the insane hypo- 
chondriac — The one talks only, the other acts and has lost his inhibitory 
power — Relations of symptoms to peripheral disease — Cases from A. K. to 
A. M. Delusional Melancholia. — Delusions from beginning the most promi- 
nent symptom — Such delusions assigned bj' relatives as the "cause" — 
Visceral cases — Electrical and religious delusions— List of the delusions of 
one hundred cases — Cases A. N. to A. W. — Prognosis in worst class of 
cases bad, as in all " fixed delusions," 53 



Vlll CONTENTS. 



LECTURE III. 

MELAXCHOLIA {PSYCH ALGIA)--continued. 

PAGE 

Excited [Motor) Melancholia. — Eestlessness, noise, agitation, wringing hands, 
moaning, shouting, tearing clothes, violence, insane obstinacy — Difficulty 
of management, hallucinations — Delirium Tremens a typical and exag- 
gerated variety of this state — Muscular expressions of mental state — Auto- 
matic misery — Cases A. Y. to B. A. — Trophic changes, boils, irritations of 
skin causing scratchings, erosions of surface, pulling out hair, etc. Resistive 
Melancholia. — Difficulty and danger of this — Masturbation — Cases B. B. to 
B. E. Convulsive Melancholia. — Whole of the functions of convolution 
affected in this — Cases B. E. and B. H. Organic Melancholia. — Precedes 
or accompanies tumors or softenings — Ends in dementia — Cases B. J. and 
B. H. Suicidal and Homicidal Melancholia. — In every case of melancholia, 
however mild, look out for suicide, and guard against it. Meaning of 
suicidal feeling — Infinite variety of motive and delusion, and of modes of 
suicide — Concealment — Cunning — Act depends much on natural courage 
of patient, and somewhat on his religious and moral principles — Prevalent 
modes of suicide in individual cases, in nations, and in sexes — Suicide by 
suggestion, from seeing means at hand — Subtlety and liability to recurrence 
of the impulse — Modes of forcible feeding — Frequency — Cases B. K. to B. 
B. — Inception of melancholia — Bodily symptoms — Causation — Termina- 
tion — Fifty -four per cent, recover — Homicidal and suicidal impulses and 
acts frequently combined — Period of life at which most frequent. Treat- 
ment. — Diet — Tonics, nutritives, sedatives, use and abuse — Stimulants: 
Quinine, iron, strychnia, phosphorus, the bromides, mineral acids, laxatives, 
mineral waters, fresh air, exercise, baths, change of air, scene, and associa- 
tion, rest, occupation, amusement, music, avoidance of excitement or noise 
or strain of any kind — Many attacks will "run their course," and "take 
their time," like a fever — Nursing, watching — Removal to an asylum. 
Prognosis. — Considerations : Youth — General state of body — Fixed delu- 
sions or not^ — Mode of onset — Hallucinations — Trophic symptoms in skin — 
Effect of treatment — Convulsions — Suicidal tendencies — Persistent refusal 
of food — Hygiene and jorojyhylaxis in children of melancholic and neurotic 
families — Diet — Mode of life and learning — Schools — Occupations and pro- 
fessions — Sleep — Cramming and competitive examinations, . . .90 



LECTURE IV. 

STATES OF MEXTAL EXALTATION— MAXIA (PSYCHLAMPSIA). 

Physiological exaltation — Sanguine variety of nervous temperament — " Excita- 
bility'' of disposition — Mental exaltation ph^-siological in childhood — 
Delirious exaltation easily excited by increased temperature in childhood — 
Exaltation and delirium occur at beginning and acme of febrile disorders 
— Depression at end and afterwards — Sane v. Insane exaltation — Exaltation 
of functions follows increased circulation, oxygenation, and heat in brain — 
Mania defined objectively, melancholia subjectively — Six varieties. Simple 
Mania. — Coherent elevation — Yarieties — Cases C. A. to C. J. Acute Mania. 
— Only forms eight per cent. — Premonitory symptoms. First Stage. — 



CONTENTS. IX 

PAGE 

Sleeplessness — XJnsettledness — Talkativeness — Constant muscular action — 
Changeability — Irritability — Diminished self-control — Extravagance — Loss 
of the sense of the proprieties, fitnesses, and conventional moralities — 
Change in the natural affections and habits — "Common sense" gone 
— Increase in imaginative power and amount of mentalization — "Whole 
man" different — Loss of body weight — Denial that anything is wrong. 
Second Stage. — Total loss of self-control — Incoherence — Violence — Destruc- 
tiveness — Filthy habits — Taste, smell, and common sensibility perverted — 
Shouting — Eoaring — Facial expression totally altered — Eapid loss of weight, 
and exhaustion of strength — Tongue and mouth dry — Secretions altered, 
and menstruation stopped. The association of ideas in incoherence — Pre- 
sentation and representation. Differential Diagnosis. — From alcohol — 
Poisons — "Suppressed " and "masked " fevers and inflammations — Injuries 
to head — Excited melancholia — A case with a new pathology. Treatment. 
— Food — Stimulants — Open air — Sedatives — Skilled attendance — General 
management — Safety — Anything that impairs appetite or digestion bad — 
Cases C. L. to C. Q. A. Delusional Mania. — Delusion the essential element, 
usually fixed, with excitement — Case of C. Q. B. Prognosis. — Not good 
— G-reatly depends on fixity and intensity of delusion. Chronic Mania. — 
Acute Mania continued in a modified way for over a year, with usually the 
elements of dementia — Cases G. Y. to C. Y. A. Treatment. — A lunatic 
asylum. Prognosis. — Bad. Ephemeral Mania. — Four forms — Case of 
C. Z. Homicidal Mania. — Cases of Willie Smith and C. T. Prevalence 
of Mania. — Fifty-five per cent. — Delusions in mania — Prognosis — Termi- 
nation — Fifty-four per cent, recover — Thirtj^ per cent, become demented — 
Five per cent, die — Prophylaxis, 123 



LECTURE V. 

STATES OF ALTERNATION, PERIODICITY, AND RELAPSE IN 
MENTAL DISEASES {FOLIE CIRCULAIRE, PSYCHORHYTHM, 
FOLIE A DOUBLE FORME, CIRCULAR INSANITY, PERIODIC 
INSANITY, RECURRENT MANIA, KATATONIA). 

Physiological alternations and periodicity — The law of "action and reaction" 
— Reproductive and sexual periodicity, with their mental changes, eleva- 
tions, perversions, irritabilities — The periodicity of neuralgia, epilepsy, 
sleeplessness, etc. — Folic Circidaire a distinct disease — First described by 
Falret and Baillarger — Three conditions in the circuit : depression, exalta- 
tion, and sanity — Duration of these vary in diflerent cases — A very incurable 
disease — Psychological interest of this disease — The same brain in different 
states — Bodily symptoms periodic too, e.g., cephalalgia, vomiting, etc. — A 
few relapses in mania or melancholia do not constitute this disease — Fre- 
quency — Commencement and termination. Treatment. — Complete the 
cure of all insanity in youth and adolescent insanity — Prevent a "brain 
habit" being formed, or a "vicious circle" being got into — The bromides — 
Non-stimulating diet — Marriage, exercise, regimen — Heredity the strongest 
predisposing cause. Pathology. — Cases D. A. to D. G-., . . . .170 



CONTENTS, 



LECTURE VI. 

STATES OF FIXED AND LIMITED DELUSION— MONOMANIA 
{MOi\OFSYCHO-JS). 

PAGE 

Delusion," popular and medical use of — Delusion from want of judgment in 
idiots and imbeciles — Delusions from ignorance and superstition — False 
sense-impressions transmitted to brain — Sleep and dreaming and nightmare 
— Definition of "Insane Delusion " — Fixity or not of delusion important — 
No pure monomania. Types most common. — Monomania of Grandeur or 
Pride. — Different forms — Has a basis in normal brain condition — Day 
dreams, etc. — Cases D. L. to D. 0. D. Monomania of Unseen Agency. — 
Connection of delusions with bodily feelings and diseases — Nocturnal 
aggravations — Cases D. 0. V. to D. T. Monomania of Suspicion. — Fre- 
quency of morbid suspicions in insanity — Insane jealousy — Fear — Con- 
cealment of delusions— Cases D. T. A. to D. T. H. — Proportion of cases — 
Diagnosis — Infinite variety of delusions and subjects of delusion. Mono- 
mania usually incurable. How it arises : 1. Out of temperament and 
disposition ; 2. After acute Inania ; 3. From brain poisoning by alcohol, or 
after traumatic injury ; 4. From perverted sensations — Legal importance of 
delusion — Importance for diagnosis and signing certificates of insanity — 
"Harmless" and " dangerous" delusions. Treatment. — Change — Distract 
mind by new ideas, new pleasures, new work — Correction of any bodily 
disorder, or any cause of irritation — Electricity — An asylum. Prevention. — 
Counteract temperament and morbid disposition by reason and good princi- 
ples and habits— Suitable choice of occupation — Temperance in all things — 
Cheerful family life — Work body rather than brain, 188 



LECTURE VII. 

STATES OF MENTAL ENFEEBLEMENT [DEMENTIA, AMENTIA, 
PSYCHOPARESIS, CONGENITAL IMBECILITY, IDIOCY). 

Physiological weakness of mind — Childhood and dotage — Weakness of mind 
in ordinary bodily diseases from starvation, exhaustion, extreme mental 
effort and tension, or emotional shocks — Definition of true dementia — 
Symptoms negative — Enfeeblement general, but not uniform, of all the 
faculties and mental powers — Originating mental power first and most 
markedly affected — No line of demarcation between sane and insane weak- 
ness of mind — A typical case of dementia. E. A. — Five varieties, (a) 
Secondary [Ordinary) Dementia. — The most common, important, and char- 
acteristic dementia of all — The natural termination of all insanities, if 
recovery or death does not occur — Acute insanities tend most towards it, 
especially acutely maniacal states — Dementia pathologically considered an 
exhausted trophic and functional state in a delicate organ originally un- 
stable, from morbid over-action — A typical case — Clinical features — 
Heredity — Acute mania — Non-recovery — Changes in expression of face, of 
tastes, habits, volition, judgment — Affective nature — Memory — Silliness 
— A mental death before the rest of the body dies — Keeducation of brain — 
Limits — Bodily health often good — Long life. Things tending to Dementia. 
— 1. Long duration of attack ; 2. Acuteness; 3. Many previous attacks; 



CONTENTS. XI 

PAGE 

4. Heredity very strong; 5. Old age — Milder forms of mental weakness, 
mental "twists," and changes, often follow attacks of insanity and apparent 
recovery — Temporary states of dementia that are recovered from after acute 
attacks of mania — Case of E. B. (6) Primary Dementia. — Imbecility and 
idiocy defined — Classification of idiocy, genetous,. eclampsic, epileptic, 
paralytic, inflammatory, traumatic, microcephalic, hydrocephalic, by de- 
privation, cretinism — Cases E. C. to E. I. (c) Senile Dementia- — Kinship 
of this to secondary dementia. Special Characteristics. — Irritability — Loss 
of memory, [d] Organic Dementia. — Kesults from softenings, apoplexies, 
tumors, and such gross brain lesions, (e) Alcoholic Dementia, . . . 204 



LECTURE VIII. 

STATES OF MENTAL STUPOR {PSYCHOCOMA). 

A distinct variety of mental disease. Definition. — Lethargy — Stupor — Impres- 
sions on senses produce no effect — Attention gone— Desire and emotion 
absent — Stupor from the physiological point of view — Connection with 
reproductive instinct — Receptivity and irritability of brain gone — Higher 
reflex functions suspended — Even reflex functions of cord lessened — Hunger 
and thirst not felt — Condition of muscles. Melaiicholic Stupor [Melancholia 
Atoniia). — An intense melancholia with delusions that "paralyze" the 
mind — Memory not gone — Sensibility not gone — Prognosis — Cases F. M. 
to F. T. Anergic Stupor- {^^ Acute Dementia"). — A real stupor — Sensi- 
bility, memory, attention, resistance gone — Feeble circulation — Yaso-motor 
paralysis. Treatment. — Vaso-motor stimulants — Continued current — 
Strychnine — Iron — Ergot — Warmth — Rubbing. Moral treatment unavail- 
ing — Causation — Prognosis — Cases F. P. to F. S. Secondary Stupor. — 
Transitory — Sequential, usually following sharp attacks of acute mania — 
Curable. General Paralytic and Epileptic Stupor. — Causation of stupor — 
Prognosis — Treatment, 217 



LECTURE IX. 

STATES OF DEFECTIVE MENTAL INHIBITION {IMPULSIVE IN- 
SANITY, VOLITIONAL INSANITY, UNCONTROLLABLE IM- 
PULSE, PSYCHOKINESIA, HYPERKINESIA, INHIBITORY 
INSANITY, INSANITY WITHOUT DELUSION, EXALTATION, 
OR ENFEEBLEMENT, AFFECTIVE INSANITY)— TlYE IN- 
SANE DIATHESIS. 

Self-control in the popular sense — Sane self-control need not be perfect — Varia- 
tion in amount of in difterent persons, ages, and conditions of society — 
Laws, natural and human, should teach it — Physiological view of inhibi- 
tion in a child — Its absence at first — Its gradual growth with brain devel- 
opment — Degrees of inhibition and of accountability — Conscience as a 
physiological brain quality — Children of criminals and of the insane — 
Organic lawlessness — Self-control aflected in all insanities — "Want of inhib- 
itory power and morbid impulse as an insanity, without other morbid 
mental symptoms — Uncontrollable motor impulses —Coughing — Sudden 
acts of defence and ofl'ence — Exhaustion lessens controlling power — Moaning 



xii CONTENTS. 

PAGE 

of irritability — Doctrine of inhibitory centres of motion, nutrition, and 
mental action— Lay cock s doctrine of reflex function of brain — Illustrated 
by maternal instinct in cats — Illustrations and cases of impulsive but 
reasoning insanity — Epileptiform character in some cases — Hereditary con- 
nection wilh epilepsy — Impulsive acts by suggestion — Brain acting auto- 
matically, just as muscles do during sleep in coughing, speaking, etc. — 
Action from impulse either by loss of controlling power, or by an excessive 
production of energy that must find an outlet somewhere — Conscious and 
unconscious impulsive action — Medico-legal importance and difficulty of 
uncontrollable action from impulse — Defective inhibition may affect every 
kind of action, every kind of affective state, and every propensity and 
instinct — Degree of strength — May result in no action, but merely a desire 
to act. Etiology. — Heredity— Sunstroke — Effects of alcohol on brain and 
offspring — Injuries to brain — Congenital defects — Want of or bad early 
training — "Moral Idiocy" — "Instinctive Juvenile Mania" — Visceral de- 
rangement and reflex irritation — Eirst symptoms of Mania or other insanity. 
Prognosis. — Depends on causes — Some of the worst and most hopeless cases 
of insanity as well as most dangerous and troublesome of this class, and 
some of the slightest. Treatment. — Protective to self and others — Change 
of scene, and removal from association of morbid ideas — Medical, by 
improving health, strengthening nervous tone, removing visceral or other 
irritation, the bromides and sedatives — Kegimen, brain rest and muscular 
exertion, nutrive non-stimulating diet, no alcohol — Educative in young 
psychokinetics. Yarieties. — (a) General Psychokinesia (Impulsiveness). 
— Cases E. L. and E. M. (b) Epileptiform, Impulse. — Impulsiveness the 
mental characteristic of epileptics — " Mental explosion " — Masked epilepsy. 

(c) Animal and Organic Impulse. — Perverted sexUal impulses, taking forms 
of impulsive masturbation, sodomy, incest, rape on children, bestiality — 
Perversion of other appetites, propensities, and instincts, e.g.., urine drink- 
ing, eating stones, rags, nails — Infinite variety of such impulses — Cases. 

(d) Homicidal Impulse. — Medico-legal importance — Examples — Letter of 
medical man suffering from this — Cases E. N. to E. N. B. (e) Suicidal 
Impulse. — Conscious or unconscious — With or without depression of mind 
— By suggestion — Instinct of love of life perverted — Most common of all 
impulses — Cases E. 0. to E, P. (/) Destructive Impulse. — Cases E. P. A. 
and F. F. {g) Dipsomania. — Importance — Causation — Il^eurotic or drunken 
heredity — Excess in drinking — Injuries to head — Losses of blood — Bad 
hygienic conditions — Special functional conditions — Menstruation, preg- 
nancy, etc. — Symptoms : Craving for alcohol and all stimulants, lying, 
general demoralization, falling in social scale, loss of all self-respect, cring- 
ing, self-indulgence, irresolution, loss of affection, Ti'eatm,ent. — Absti- 
nence, isolation, work, healthy food, regimen, and conditions of life. 
Prognosis. — Bad in most cases — Cases F. B. to F. D. (A) Kleptomania. — 
Bare in uncomplicated form, but this impulse very common in man}^ forms 
of insanity, especially in general paralysis, and less so in mania and con- 
genital imbecility, (j) Pyromonia. — Bare in uncomplicated form — Case of 
F. E. [k) Moral Insanity. — Congenital absence of sense of right and 
wrong, and incapacity for moral education — We find persons with no moral 
sense, no remorse, no love of the good, but a love of and impulse to do 
•every evil thing — Cases F. H. to F. L. — Conscientiousness hereditary, . 231 



CONTENTS. xni 



THE INSANE DIATHESIS {NEUROSIS INS ANA). 

PAGE 

Maudsley's and Morel's description — Characterized by striking peculiarities, 
eccentricities, oddities, disproportionate developments, abnormal afltective- 
nesses, impracticalness, impulses, irregular action a,nd modes of life without 
motives like other men — Connection with the neurosis and with genius — 
Functional manifestations of unstable nerve element in its receptive and 
reaction aspects — Seen in childhood — Importance of right up-bringing and 
education of body and mind — Case of E. M., 257 



LECTURE X. 
GENEKAL PAEALYSIS. 

A true disease, a pathological entity — Not a mere group of symptoms — Its im- 
portance and interest — Definition — Three stages — A typical case in first 
stage. Etiology. — Temperament — All causes of brain exhaustion and irri- 
tation — Excesses in drinking — Sexual excesses — Overwork — Over-anxiety 
— Syphilis — Injuries — Age at which it occurs from twenty-five to fifty. 
First Stage. — Elevation — Iijcrease of sense of wellbeing — Constant motion 
— Loss of sleep — Exalted delusions — "Ambitious delirium" — Facility — 
Fibrillar tremblings of tongue — Pathognomonic speech — Slight incoordi- 
nation of muscles of hands and legs — Extravagant conduct — Acutely 
maniacal state — Danger to patient's life — Difficulty of management — 
Increase of temperature, especially in evening. Second Stage. — Acute 
excitement passing off — Greater facility and general silliness of mind — 
Speech, writing, and walking affected — Dilated pupils — Spurts of excite- 
ment — Progression of the paretic symptoms — Kleptomaniacal symptoms — 
Surplus stock of motor energy easily exhausted by walking — Fragility of 
bones — Epileptiform fits — "Congestive attacks." Third Stage. — Paresis 
becomes paralysis — Inability to walk or speak — Occasional restlessness — 
Trophic lesions — Bed-sores — Swallowing impaired — Tendency to choke — 
Kelaxation of sphincters — Sensibility deadened — Duration from eighteen 
months to three or four years — Kemarkable exceptions. Two Pathological 
varieties. — 1. The cerebral or ordinary; 2. The tabic or eccentric by patho- 
logical propagation — The cerebral by far the most numerous. Symptomato- 
logical varieties. — 1. Non-delusional ; 2. Epileptiform ; 3. Eemissional 
where apparent recovery takes place for a time ; 4. Simply maniacal ; 5. 
The long-lived ; 6. The melancholic. Chiej" Pathological Appearances. — 
Skull-cap thickened and hardened — Dura mater adherent — General conges- 
tion — Thickening of pia mater — Adhesion of pia mater to convolutions — 
Atrophy, general and interstitial — Lining membranes of ventricles granular 
— Hardening of tissue — Outer laj^er of gray substance diseased — Prolifera- 
tion of nuclei — Destruction of nerve-cells — Pachymeningitis haMnorrhagica 
— Essential mental feature is progressive enfeeblement and facility — What 
is general paralysis? — It is the special and peculiar disease of the mind 
tissue — Local prevalence. Diseases with which it may he confounded. — 
1. Alcoholism; 2. Syphilis of brain; 3. Epilepsy; 4. Acute Mania; 5. 
Tumors of brain; 6. Brain atrophy; 7. Chorea; 8. Partial Aphasia; 
9. KamoUissement — Cases from F. Y. to G. M., 260 



XVI CONTENTS. 

LECTURE XIV. 
UTERIXE, OR AMENORRHOEAL AND OVARIAN INSANITY. 

PAGE 

Influence of menstruation on mind — Of insanity on menstruation — Two forms : 
melancholic and maniacal — Cases J, Q. to J. S. — Delusions of patients 
often tinctured by diseases or disordered functions of ovaries and uterus — 
Ovarian " Old Maids' Insanity " — A baseless passion of an unprepossessing 
oldmaid— Caseof J. T., 336 

HYSTERICAL INSANITY. 

Insanity engrafted on hysteria — Sj'^mptoms of both combined — Hystero-epilepsy 
— Laughing — Crying — Incessant talking — Mock modesty — Sexual and 
erotic ideas — Imaginary ailments — Craving for notice — Masturbation — 
Dirty habits. Treatment. — Tonics — Baths — Occupation — Moral treatment 
— Discipline — Antispasmodics — Bromides — Attention to female health — 
Non-stimulating diet — Complications and combinations of adolescent, hys- 
terical, and masturbational insanities — Letter of hysterical maniac — Occurs 
in over two per cent, of female cases of insanity — Sixty per cent, recover — 
Cases J. IJ. to J. Y., \ . . . . 340 

INSANITY OF MASTURBATION. 

Habit of masturbation very common and injurious to boys of neurotic tempera- 
ment — Masturbation as a symptom and complication of insanity — Characters 
of insanity of masturbation — Self-feeling — Introspection — Solitary habits — 
Perverted emotionalism — Depression — Vacillation — Cowardice — Suicidal 
feelings — Maniacal attacks — Impulsive acts of violence. Bodily signs. — 
Pains in back — Pains in head — Ringing in ears — Palpitation, etc. — Forms 
2.2 per cent, of all insanity. Treatment. — Tonic — Bracing diet — Regimen 
— Baths — Occupation — Muscular exercise — No local means — Occurs in 
fifteen per cent. — Twenty-five per cent, recover — Cases J. W. to K. A., . 342 



LECTURE XV. 

PUERPERAL INSANITY. 

Limited to that occurring six weeks after childbirth — Importance of this form — 
Five per cent, of the insanity among women — Occurs in one in four hun- 
dred labors. Symptoms. — Change of manner — Inattention — Carelessness 
about child — Danger to child's life — Incoherence — Mania — Eroticism — 
Feeble pulse — Weak bodily state — Stoppage of lochia — Septic condition of 
womb — High temperature — Tenderness over womb. Treatment. — Good 
nursing — Feeding often — Stimulants in large quantities — Sedatives — 
Asylum treatment depends on circumstances of patient — Counter-irritation 
over uterus — Antiseptic washes — Statistics — Ages — Heredity — Moral causes 
— Illegitimacy — One of the cases after first labors — Begins in fifty per cent, 
within first week after delivery — In eighty per cent, within first fortnight 
— Most cases acute — Seventy-five per cent, recovered — 8.3 per cent, died — 
Cases K. B. to K. G., . ". 349 



CONTENTS. XVll 



INSANITY OF LACTATION. 

PAGE 

An anaemic insanity — Occurs most commonly after prolonged lactation — Eisk 
greatest after several children — Mental symptoms melancholia and mania — 
Premonitory symptoms usually present — Hesidnches-^Tinnitus aurium — 
flashes of light — Irritability — Precordial anxiety — Forms over four per 
cent, of insanity in females. Prognosis. — Good — Seventy-seven and a half 
per cent, recover. Treatment. — Stop nursing — Tonic and Supporting — 
Statistics of forty cases — Case of K. J., 359 

INSANITY OF PREGNANCY. 

Rare — The psychology of pregnancy — Occurs most frequently in a mild form — 
Usually melancholic — Suicidal tendency in half the cases — Connection of 
the insanity with the morbid cravings, etc., of pregnancy — Few cases of 
stupor — A few of dipsomania — Only a few of the severe cases recover at 
childbirth — Sixty per cent, recover — Cases K. L. to K. O., . . . 363 



LECTURE XVI. 

THE INSANITIES OF THE TIMES OF LIFE. 

Enormous differences in the physiological activities of the brain at different 
periods — Type of mental derangement much influenced by the special 
physiological activity or decadence of the period, ..... 368 

INSANITY OF PUBERTY. 

Rare — Only two cases in Royal Edinburgh Asylum at ages of 14 and 15 out of 
1800 cases, and only twenty-two at 16 and 17 — Always hereditary — Acute 
— Remittent — Not dangerous to life — Maniacal — Theories and practices of 
education at puberty — Half the general population are under 20 — Only 1.5 
per cent, of the insane under 20 — 8 per cent, of general population over 60 
— 17 per cent, of the insane. Prognosis. — Good. Treatment. — Tonics — 
Fresh air — Baths — Milk and farinaceous diet — Cod-liver oil — Bromide of 
potassium — No opium or chloral — Case of Iv. P., .... 368 

INSANITY OF ADOLESCENCE. 

Meaning of Adolescence — Physiological and psychological characteristics — 
Momentous period — Far more so than puberty — Novelists the best students 
and describers* of the mental characteristics of adolescence — Gwendolen 
Harleth {Daniel Deronda) — Relationship of adolescence to emotion — Sense 
of duty — Capacity for work — Sentiment — Religious sense — Courtship — En- 
gagements to marry — Sexual intercourse — Of 1800 cases 230 uncomplicated 
between ages of 14 and 25 — Of these 49 occurred at the ages of 18, 19, and 
20, while 157 occurred from 21 to 25. • Mental Symptoms. — 78 per cent, 
exaltation — Only 22 per cent, depression — Mania, acute, remittent, relap- 
sing in 66 per cent. — Hereditary predisposition very common (45 per cent, 
ascertained, far more than that in reality) — Morbid ideas, emotions, speech, 
and conduct tinctured by erotic, sexual, or adolescent characteristics. Prog- 
nosis. — Good — At least 66 percent, recover — Remainder mostly become de- 
mented and live long, bodily health often being good. Mortality Small. — 

B 



XVlll CONTENTS. 

PAGE 

Only 1.8 per cent. died. Treatment. — Same as for insanity of puberty. 
Signs and Accompa7iiments of Recovery. — Perfect development of form and 
mammae — Growth of beard and sexual hair — Change of voice — Psycho- 
logically and bodily they emerge from attack men and women — Case from 
K. Q. to K. Y., .375 



LFCTURE XVII. 

CLIMACTEPvIC INSANITY. 

Normal psychology and physiological characteristics of period. Mental Symp- 
tom.^ in Typical Case. — Loss of keen interest in life — Fits of depression — 
Capacity for work diminished — Irritability — Suspicion. Sense of Fear 
and Impending Danger. — Change of connubial affection — Suicidal longings 
— Yague melancholic delusions. Bodily Symptoms. — Sensory neuroses — 
Yertigo — Pains — Sensations of heat — Yaso-motor neuroses, flushings, etc. 
Motor Symptoms. — Kestlessness — Statistics of two hundred and twenty- 
eight cases — Ages — Character subacute and melancholic — Fifty-three per 
cent, recovered — Duration of attack. Treatment. — Change of scene — 
Travel — Change of air and diet — Iron and quinine — Sea-bathing — Fresh 
air— Fattening diet— The bromides— Cases K. Y. to K. Y., . . . 388 

SENILE INSANITY. 

Normal psychology of old age — Senile insanity — Heredity low — Yariety of 
mental symptoms — Automatic misery and suicidal attempts — Transient 
cases — Short delirium before death — The dotards — Senile suspicions — Ke- 
fusal of food — Ages — Thirty-five per cent, recovered — Mortality. Pa- 
thology. — Kelationship to atheroma of arteries, shrinking of brain, and de- 
generation and atrophy of cells of convolutions — Apoplexies — Softenings. 
Treatment and management. — Nursing — Support — Sedatives — Stimulants 
—Diet— Cases L. A. to L. G., 395 



LECTURE XVIII. 

THE BARER AND LESS IMPORTANT CLINICAL YARIETIES OF 
MENTAL DISTURBANCES. 

. Ansemic insanity — 2. Diabetic insanity — 8. The insanity of B right's disease 
— 4. The insanity of oxaluria and phosphaturia — 5. The insanity of cyanosis 
from bronchitis, asthma, and cardiac disease — 6. Metastatic insanity — 7. 
Post-febrile insanity — 8. Insanity from deprivation of the senses — 9. The 
mental disturbance of myxoedema — 10. Insanity a^^sociated with exoph- 
thalmic goitre — 11. The delirium and mental disturbances of young 
children — 12. The insanity of lead-poisoning — 13. Post-connubial in- 
sanity — 14. The pseudo-insanity of somnambulism, 411 



CONTENTS. XIX 



LECTUKE XIX. 

MEDICO-LEGAL AND MEDICO-SOCIAL DUTIES OE MEDICAL MEN 
IN RELATION TO INSANITY. 

1. Taking the responsibility of advising the restriction of liberty, and placing 
cases under the care of attendants at home. 2. Signing medical certificates 
of insanity, in order to place patients in asylums and under care in private 
houses: (a) Is the patient insane? [b] If so, is he " a proper person to be 
detained under care and treatment?" (c) Why should he be placed in an 
asylum or sent from home ? (d) Is there any legal risk to those who take 
the steps for asylum treatment ? (e) Eill up even the formal part of the 
certificate up to "Facts" carefully; (/) "Facts indicating insanity ob- 
served by myself" the most important part of certificate — Delusions — Ap- 
pearance and manner of patient — Expression of face — Incoherence — Want 
of memory — Change from natural condition — Suicidal or homicidal expres- 
sions — Taciturnity — Quote words used — Put no redundancies — Cumulate 
facts — Use facts observed at other interviews; (g) "Facts communicated 
by others," corroborative — Attempts at suicide — Assaults — Paroxysmal 
aggravations ; (A) Get the cue to delusions, etc., from others before you 
see patient ; (i) Necessity for tact — Sometimes a little stratagem — Cunning 
and reticence of patients ; {k) Cannot keep patients in private houses with- 
out certificate in England, or notice to Commissioners in Scotland. 3. Giving 
certificates of sanity — Need for care and caution. 4. Giving certificates as 
to the appointment of a curator bonis in Scotland, and making afiidavits 
and giving evidence before a master in lunacy in England and Ireland 
when a commission de lunatico inquirendo is held by him. 5. Giving 
evidence as to the existence of mental disease or not in criminal cases, to 
enable the law to fix or absolve from responsibility, before higher and lower 
courts, and as adviser to procurator-fiscal in Scotland. Crimes most com- 
monly com'initted in Mania. — Epileptic, Alcoholic, Puerperal, and Simple. 
Melancholia. — Delusional. Dementia. — Impulsive violence. Impulsive 
Insanity. — Homicidal, kleptomania, pyromania, animal impulse — Compli- 
cations of insanity with drunkenness — Somnambulism and allied states 

Divergence of medical and legal views. Successive Legal Views. — Wild 

beast theory (Tracey) — Knowledge of right and wrong (Mansfield) 

Knowledge of right and wrong as to the act (Twelve Judges) — Delusional 
test (Denman) — Habit and repute (Moncriefit") — Power of control (New 
Criminal Code, Stephen) — Difficulty of cases on the borderland — Necessity 
for caution, full knowledge of all the facts, and strict impartiality. 6. 
Will-making. — Is he free from the influence of drink or drugs? Does he 
understand the nature of the act he is doing, and the effect of the document ? 
Is the disposition of the property a natural one ? Is it not influenced by 
insane delusion or insane state of mind ? Is there no facility with undue 
influence being exerted? Can he tell' twice over the disposition ho wishes 
to make ? Does he know how much property he has ? Do not let a good 
motive sanction a bad will. 7. Detecting Feigned Insanity. — No general 
rule — Are the symptoms those of any known type of insanity? Is there 
any motive? Watch the patient when he thinks ho is unobserved — Over- 
does his part — Power of endurance — Sleep — Sensibility — Sudden shocks, 
electric battery, etc. — Hysteria — Effect of drugs — Difficulty of this i]utvti»>u 
— Imitations of aggravated insanity— Self-accusations of really insane people. 



XX CONTENTS. 

PAGE 

8. Giving confidential family advice as to such matters as engagements to 
marry, education, choice of profession, sudden changes of conduct and 
morals — Dreadful effect of helping to increase the neuroses, the insanity, 
and the idiocy in the world — On the other hand, Maudsley's opinion as to 
the genius that may result from neurotic marriages — Special mode of educa- 
tion sometimes needed for neurotic children, ...... 423 



APPENDIX. 

Abstract of the Statutes of the United States, and of the several States and 

Territories, relating to the custody of the insane, ..... 435 



DESCRIPTION OF THE PLATES. 



PLATE I. [Frontispiece.) 

Appearance of the vertex of one hemisphere of the brain in a case of advanced 
General Paralysis, a, Skull-cap condensed, h, Anterior third of brain, as 
seen when dura mater was first raised, showing thickened milky arachnoid 
dotted over with small white spots, with the opaque turbid compensatory fluid 
under it, and the tortuous dilated veins, congested vessels, the convolutions 
showing dimly through, c. Middle third of brain, showing the appearance of 
the convolutions after the pia mater has been removed. They are congested, 
and the outer layers of gray substance have been torn away in irregular patches, 
from the most projecting part of many of the convolutions having adhered to 
the pia mater and been removed with it. The portions so removed have left 
ragged, eroded-looking spaces where the gray substance looks softened, while the 
outer layer looks hard and opaque on its surface, d, Shows the pia mater 
stripped from middle third of brain, hanging down, concealing posterior lobe 
of brain, and showing the appearance of its inner surface with the portions of 
the convolutions adhering to it. It is congested and thickened, so that, instead 
of being like the normal pia mater, a delicate, filmy, transparent membrane, it 
is a tough, spongy-looking texture. 

PLATE n. (Page 140.) 

Fac-simile of a letter written by a maniacal patient, showing incoherence, rapid 
change of ideas, delusions, hallucinations of sight, an insane association of 
ideas, and an insane symbolism. 

PLATE III. (Page 156.) 

The appearance of a section of the anterior lobe of the brain in a patient who 
had died of the exhaustion of acute mania. It shows — a, the congested gray 
substance of the convolutions ; h, congested white substance near gray matter : 
c, an inner ring of still more intense congestion along the line of junction of the 
gray and white substances, and extending into the white substance ; and d, 
limited areas of congestion in the white substance. This is a type of the irregu- 
lar vascularity seen in the brain very commonly in insanity, indicating probably 
during life a disturbed vaso-motor condition, which may bo either the proximate 
cause, or a necessary accompaniment, or the effect of the mental disturbance. 



XXll DESCRIPTION OF THE PLATES. 



PLATE lY. (Page 187.) 

Great tliickeuing of skull-cap aiiteriorl3% with enormous deposits of new osse- 
ous tissue in an irregular nodulated way on the inner table of skull, in a case of 
alternating insanity of over twenty years' duration. This is an aggravated 
example and t3'pe of what is almost universal in chronic insanity with periods of 
excitement. It is a proof of the structural effects of such repeated congestions 
of the branches of the carotid artery, even in the hardest tissue, and may be 
fairly considered to be of the same nature as the brain changes in the same 
cases, which are not so evident, but are no doubt far more important. The 
atrophy of the anterior lobes of the brain that usually accompanies such bony 
thickenings and deposits probably helps the tendency, there being nothing but 
dura mater and cerebro-spinal fluid immediately under such growths. 



PLATE y. (Page 306.) 

A section through the brain of a man who had labored under syphilitic in- 
sanity (the third or vascular form), with slow arteritis affecting the vessels sup- 
plying the anterior and part of middle lobes of one hemisphere. This had 
caused slow starvation and absorption of nearl}^ all the white substance in the 
centre of those lobes, leaving the gray matter of the gyri almost intact, so that 
there was a bag of fluid inside with the convolutions as its walls. The convo- 
lutions looked at from the inside are quite defined, and look as if the white 
substance had been carefully scraped off them. This illustrates the greater 
vascularity, and consequent greater vitality, of the gray matter as compared 
with the white, as well as the different sources of the chief blood-supply of each. 



PLATE VL (Page 165.) 

A chart showing the relative prevalence of Melancholia (thin line), Mania 
(thick line), and G-eneral Paral3'sis (dotted line), in the Royal Edinburgh 
Asylum, and the ages at which those three conditions are most prevalent. The 
numbers per 1000 of the total admissions run along the sides, and the ages 
along the top and bottom of the chart. It is seen that most cases of melan- 
cholia occur between 35 and 40, while the highest number suffering from mania 
occurred between 20 and 25. The melancholic line keeps high all through the 
end of life. General paralysis is scarcely found at all before 25, reaches its 
acme between 40 and 45, and is not found at all after 57. While maniacal con- 
ditions rise highest as adolescence is completed, between 20 and 25, they rise 
very high again at the period when melancholic conditions prevail most, between 
35 and 40 ; that is, when the mental and moral causes of insanity are most 
prevalent, when the business troubles, domestic worries, the afflictions, and the 
keen competitions of life are most common or most intensely felt. 



DESCRIPTION OF THE PLATES. XXlll 



PLATE VIL (Page 83.) 

Five microscopic drawings. Fig. 1. Cells of semilunar abdominal ganglion of 
a very bad case of visceral melancholia, in a condition of' atrophj^, degeneration, 
and pigmentation. This patient had intense delusions that she had no stomach, 
and that her bowels were never moved. She had no appetite, and she obsti- 
nately refused food, and died of exhaustion, though regularly fed with the 
stomach-pump. 

Fig. 2. A marked apoplexy in a convolution, such as seen frequently in a 
lesser degree in acute mania, general paralysis, syphilitic insanity, senile insanity, 
and epileptic insanity (after Dr. J. J. Brown). 

Fig. 3. An epithelial granulation, from the floor of the fourth ventricle of a 
case of advanced general paralysis, showing the enormous proliferation of the 
epithelial cells. There is one or, at the most, two normal layers of delicate 
epithelial cells in this position ; but as seen in the section they have increased a 
thousandfold, and have altered entirely in appearance. At the summit of the 
granulation they are round, at its base flattened, while under it we observe a 
sclerosed layer of nervous tissue, with the neuroglia enormously increased in 
volume. 

Fig. 4. The proliferated and much enlarged nuclei of the neuroglia, from a 
convolution of an acute case of general paralysis, who died of epileptiform con- 
vulsions. Those nuclei are seen to follow the course of the capillaries in some 
places, sometimes even taking their place, the vascular tissue having disappeared 
altogether. 

Fig. 5. A very interesting section of the outer part of a convolution of a case 
of general paralysis, as seen under a low power. The section had been forgotten 
in water, and had undergone partial maceration, so that the nerve cells and 
fibres had disappeared, leaving only at the free surface of the convolution the 
thickened pia mater full of nuclei, then under that the condensed and altered 
outer layer of gray substance, which is adherent to the pia mater in general 
paralysis, with few capillaries, then under this is seen the finer network of 
capillary vessels, and deeper still the more open network of vessels towards the 
white substance. All these vessels were seen under a high power to be con- 
gested, their coats thickened and covered with adventitious fibrous substance 
and proliferated nuclei. The actual space left for the nerve cells is much dimin- 
ished in such a case. The gradually increasing fineness of the vascular reticula- 
tion in the gray substance of a brain convolution as we approach its peripheral 
surface, a fact to which there is little reference in works on histology, is here 
very well seen. A section of a normal convolution would not have held 
together at all under this treatment. 



PLATE VIII. (Page 306.) 

Fig. 1. A small artery in the brain, with all its coats enormously thickened, 
separated from each other, and its lumen almost obliterated, as found in eases 
of syphilitic insanity, senile insanity and other forms (after Dr. J. J. Brown\ 



XXIV DESCRIPTION OF THE PLATES. 

Fig. 2. Starved brain cells in a convolution, supplied by such an arterj^ as seen 
in Fig. 1. The cells are in various stages of degeneration and atrophy, their 
walls, processes, and nuclei having disappeared (after Dr. J, J. Brown). 

Fig. 3. A portion of starved and atrophied brain substance, from a convolu- 
tion of a case of senile insanity. The whole substance is loose, reticulated, and 
almost destitute of brain cells in upper part of section, with only the packing 
tissues and vessels left. 

Fig. 4. Cells from the brain convolution of a case of senile dementia, showing 
their degeneration, atrophy, and pigmentation. Their nuclei remain, but their 
processes have fallen off. Probably this illustrates a natural decay of the cell 
itself rather than a blood starvation as seen in Fig. 2 (after Major, West Riding 
Asylum Medical Reports, p. 170). 

Fig. 5. Shows a new lesion of the brain discovered by Dr. J. J. Brown, in a 
case of acute mania in the Royal Edinburgh Asylum, in 1877. This is a section 
from a convolution, showing its free surface at upper part of section, from which 
the pia mater had been removed, and in the part of gray substance drawn an 
enormous deposit of a new substance, taking up most of its middle laj^ers. It 
appeared in masses, in smaller nuclei-like bodies, and also round the vessels. 
The larger cells seen in the inner layers of the gray substance were somewhat 
degenerated and atrophied, their processes having disappeared. 



PLATE I. 




James Robertson. Del' 



vVaterstoni.SoT>i LitLo. Edinbnrg! 



THE VERTEX OF THE BRAIN IN ADVANCED GENERAL PARALYSIS 



CLINICAL LECTURES ON MENTAL DISEASES. 



LECTURE I. 

THE CLINICAL STUDY OF MENTAL DISEASES. 

All classes of men have generalized ideas of mind according to the 
daily experience and the practical necessities of life of each. It is not 
left to the philosopher, metaphysician, and psychologist to study mind. 
The jurist, politician, priest, and sociologist each has his own system of 
mental philosophy. Nay, the policeman and the house-breaker have each 
a crisp and concise theory, learned in the schools of experience and 
tradition — not formulated it may be, but still definite and practical. 
The physician in practice has, more than most men, opportunities of 
seeing a wide range of mental phenomena. He comes into intimate 
personal relationship with men and women in circumstances where the 
reasoning and feelings, the instincts and propensities of human nature, 
are exposed to his view Avith as little concealment or hypocrisy as pos- 
sible. There are very few of the serious diseases he treats but affect the 
minds of his patients more or less in some way. He has to study care- 
fully the effects of their outward surroundings and of the impressions 
from without on the minds of his patients. He has to calculate the effect 
of his own speech and conduct, as well as those of all who surround 
them. He has to do with mind in its most undeveloped form up throuo'h 
all its stages of growth and education, and he has the opportunity of 
seeing the effects on it of every form of disease and debility. In addition 
to this he is called on to treat mental symptoms when, through their 
striking abnormality, they have themselves become a disease. 

The whole conduct of things in the world is necessarily so based on 
the assumption that every man is a responsible being Avith a sound mind, 
that any exception to this, when it occurs, has a very startlino- effect. 
In the early ages it was not admitted that such a thing was possible, and 
when a man's mind Avas clearly altered from its normal state, and his 
mental personality changed, they explained it by the theory that some 
other personality had entered temporarily into the man, driven out and 
overpowered the true occupant, and that the man was possessed with a 
devil, or some spirit good or bad other tlian his own. It is certainly no 
Avonder that before the physiology of tlie brain Avas studied such a theory 
Avas adopted. The facts Avere so inexplicable on any current hypothesis 
of mind, that they needed a supernatural cause. Looked at from the 
human and social point of vicAV, no other disease at all approaches 

3 



34 CLINICAL STUDY OF MENTAL DISE ASES . 

mental disorder in the terror it inspires, the sense of helplessness it 
causes, the deep distress to relatives, and the disturbance of all social 
ties. It is no wonder that its study was backward, and its treatment 
barbarous, up till quite recent times. But the modern scientific spirit 
could not, and did not, allow this field to lie fallow, and its study was 
hardly begun when its profound interest and great importance were seen. 
It was soon recognized that the mode of study of this department must 
be precisely the same as that required for physiology and pathology. 
The physiologist had to study normal mind as a form of brain energy ; 
the physician had to investigate abnormal mind in the same observational 
and inductive way as he studied diseases of the chest. It was very soon 
apparent that the brain was the sole organ of mind, and that the func- 
tions of that organ, being multiform, and having relationship to every 
part and energy of the body, could only be properly studied in relation 
to one another. It was found impossible to place quite apart the motion 
and sensation functions, the sleep, the animal appetites and instincts, the 
special senses, the speech, the memory, the love of life, the affective, 
the reasoning, and the controlling functions. The great problems thus 
opened up have exercised a fascination over many of the greatest men in 
our profession in modern times, men w^hose general professional work did 
not lie specially in the treatment of mental disease. I need only men- 
tion Pinel, Esquirol, Feuchtersleben, Pritchard, Abercrombie, Combe, 
Schroeder van der Kolk, Brodie, Holland, Griesinger, and Laycock. 
And as for the pure psychologists who have lately studied mind from the 
physiological point of view their name is legion. In this country alone, 
Herbert Spencer, Darwin, Huxley, Lewes, Maudsley, Calderwood, and 
Bain represent a power of original investigation and exposition seldom 
excelled in any one department of science ; and this is not wonderful, for 
if the highest functions of the brain and its derangements are not worthy 
of study by the best minds, what can be supposed to be so ? 

In a strict sense the term "medical psychology" is a misnomer; if 
psychology is a real science, it is one and indivisible, and you might as 
well talk of medical mathematics or medical physics as medical psy- 
chology. But inasmuch as medical men seldom have the time, and only 
a few of them the special aptitude, for the study of the whole field of 
psychology, that portion of it which has a relation to their physiological 
studies and the practical work of their profession has been divided off — 
not, it is true, by very defined lines — and called Medical Psychology, 
just as certain departments of electricity and acoustics may be called 
medical par excellence. An unambitious definition of medical psy- 
chology might be " Mind — as it concerns Doctors." 

The necessity which exists for a knowledge of mental disease to medical 
men is best proved by a few facts and figures. An exceptional power 
has been granted by law to every member of our profession in practice 
of giving a certificate, the effect of which is to deprive any British sub- 
ject of his personal liberty on the ground of insanity. Surely such a 
responsibility implies an obligation on our part to know something about 
the subject of mental disease. How can we know that which we do not 
study ? And how can the medical practitioner give advice and sign such 
all-important certificates about a disease which, as a medical student, he 



CLINICAL STUDY OF MENTAL DISEASES. 35 

has never seen or had explained to him clinically ? As well might you 
ask a man to give a life-insurance certificate that a patient was free from 
heart disease who had never listened to a cardiac murmur. This ignor- 
ance is fraught with an unusual danger. While allowing — nay, practi- 
cally compelling — us to grant lunacy certificates, the law punishes us 
severely Avhen they are improperly given, whether through mere ignor- 
ance or wrong intention ; and the common law of the land allows any 
man who thinks he has been aggrieved or wronged by such a certificate 
to sue and punish the grantor of it. Several members of our profession 
have thus been brought into most serious trouble, professionally and 
financially, and themselves to pecuniary ruin. The fact that, out of 
12,176 medical certificates of insanity in the admission papers sent to 
the ofiice of the Commissioners in Lunacy, 2314, or one-sixth, had to be 
returned to the writers for amendment, does not, I fear, tend to raise the 
opinion of the lawyers, to whom those certificates are submitted, as to 
either the business power or the knowledge of insanity in our profession. 
I fear they are apt to ask — If the knowledge necessary to sign an 
ordinary lunacy certificate is so deficient, what may be expected in the 
still more important matter of the knowledge requisite for the treatment 
of the disease ? I have had the 500 recent certificates sent to the Royal 
Edinburgh Asylum gone over, and I find that 456 of them, or 91 per 
cent., omit a certain point, not at all important from a medical point of 
view, but so essential from a legal point, that Sir Cresswell Cresswell 
once decided that it was a sine qua non of a valid and legal certificate 
according to English law.^ And it is not as if the signing of a certifi- 
cate of lunacy were a matter of rarity. There were last year over 
90,000 persouo un ler certificate as being insane in the United Kingdom. 
This number required over 100,000 medical certificates, or an average of 
at least five certificates to each practising member of our profession. 
This takes no account of the certificates of mental incompetency or com- 
petency that have to be granted for other reasons than placing a patient 
under care. The signing of such certificates is one duty, but not the 
most important, that falls to medical men in relation to mental disease. 
The mental hygiene of individuals, of families, and of society, the early 
recognition of mental symptoms, their suitable treatment, the precautions 
that have to be taken to prevent accidents and risk of life, the solution 
of the most important question of home or asylum treatment, the confi- 
dential family advice as to professions and careers in life, and as to the 
formation of engagements and marriages, the grave decisions that have 
to be come to as to questions of civil and testamentary capacity and 
criminal responsibility — all or any of these questions a medical man may 
have before him at any time after he receives his medical qualification. 

When we consider that one in every 300 of the population is a regis- 
tered certified lunatic, the marvel is how our profession has hitherto got 
along so well with so little S3^stematic teaching or clinical experience of 

^ The dosii;-iiation and rosideuco, marked 4 in the statutory form. Tho lo>;-al im- 
portanoc of tliis part consists in the fact that it is the only part of the oertiticate 
where the patient is fully identitied. Suppose "John Brown" is beinsx certitied 
without his designation and residence, what means is there of legally distinguishing 
him from the thousands of the same name in the countrv ? 



8(5 CLINICAL STUDY OF MENTAL DISEASES. 

mental disease. We must remember that for every person who is ob- 
viously insane there is probably another Avho has been threatened at some 
period of his life with its symptoms, or labors under more harmless and 
less obvious varieties of it. If this vast mass of brain disease is not 
worth study, let the general profession be freed from responsibility in 
regard to it ; if this cannot be done, then, in the name of all that is 
reasonable, let its study find a place in every medical curriculum, as 
urged by the Earl of Shaftesbury, the veteran head of the English 
Lunacy Commission for the past forty years, and by almost all the 
medical witnesses of repute who gave evidence before the Lunacy Law 
Committee of the House of Commons of 1877. But for invidious com- 
parisons, I think that I could show that there is more than one subject 
which medical students have now to study, and on which they undergo 
searching examinations, that cannot compare in practical importance with 
mental diseases. 

From another point of view the study is important, for there are now 
more than 500 medical appointments held in the three kingdoms in con- 
nection with the treatment of mental diseases, as Commissioners in 
Lunacy, Lord Chancellor's Visitors, Inspectors of Asylums, Medical 
Superintendents, Assistant Medical OflBcers, and Consulting Medical 
Officers to Asylums. Most of those appointments are held by those who 
never had the opportunity of studying in any scientific or clinical way, 
when students, the subjects of mental disease. 

Much nonsense is now-a-days talked about the relationship of the so- 
called specialties in medicine to the profession in general. On the one 
hand, they are referred to in a mysterious way, as though they w^ere 
occult and very sacred side chapels, ofi" the temple of medicine, to enter 
which special rites had to be gone through ; and, on the other, they are 
spoken of as ugly excrescences on the noble form of the building. They 
are, in fact, simply the result of the enormous increase of knowledge, 
which renders one man or one set of men incapable of being equally 
versed in the whole field. The science of medicine has become so wide 
that Ave can only cultivate it in parts. Therefore w^e specialize, and must 
specialize more and more. But, most fortunately for the future unity of 
our profession, its practical exigencies are such that most of its members 
must know something of all its specialties. The further out the speci- 
alty is from the main roads, the w^orse it is for itself in the long-run. 
It is thus most difiicult to avoid narrowness and the self-complacent con- 
ceit that always goes with narrowness. The department of medicine 
that has to do with the treatment of mental disease is, unfortunately for 
itself, a rather strongly marked specialty, for when patients are very ill 
they must be sent to hospitals for the insane, under the charge of medical 
men w^ho make that their business, and do not usually practise much be- 
yond those hospitals. But then most cases have to be treated at home 
for a time at first by the family physician, and many cases do not need 
to be sent to those hospitals at all, but can be treated outsic^e them. 
And as time goes on, our knowledge of mental disease will become more 
generally diffused and more accurate, and such hospitals will be opened 
as fields for clinical study, as one department of Morningside Asylum 
has been for many years past, this having been one of the original inten- 



CLINICAL STUDY OF MENTAL DISP:AS1i:S. 37 

tions of its founders, as stated in its rules. The state of things to be 
aimed at no doubt is, that all medical men should know something of all 
the specialties, that all specialists should be well grounded in general 
medicine and surgery, and that they should habitually mix with each 
other to widen their ideas. There is a law of demand and supply in 
this matter as in all others. If the general public did not put faith in 
specialists for certain special diseases, it would not consult them, and 
they would cease to exist. 

The study and treatment of the diseases of the mental functions of the 
brain has such close relations to the study of all other brain functions, 
and to the treatment of all other brain disorders, and the brain is so 
incontestably the dominant organ of the body, affecting all its tissues, 
controlling all functions, regulating all its energies, that there ought to 
be less risk of its study producing narrowness, or one-sidedness of view, 
than almost any other specialty. If mind is great, surely the special 
study of its derangements cannot be a belittling task. It might well be 
argued that this study is the highest branch of medicine, inasmuch as it 
is confessedly the most difficult, and relates to the most important part of 
man. The existence of mental disease aifects the position and prospects 
of those who suffer from it more than any other disease whatever, and 
society and the State take more direct control of them than any other 
class except the criminals. When any other organ is affected by disease, 
it is, after all, merely a part of the man that suffers ; when the convolu- 
tions of the brain go wrong in their mental functions, it is the man him- 
self that is affected. The rest of the human organism, looked at teleo- 
logically, subserves the brain, and all the other functions of that organ 
subserve the mental. Everything that lives, looked at from the evolu- 
tional point of view, tends towards mentalization, and all the tissues of 
all the nervous organs of all the types of animal life find their acme in 
the human brain convolutions. From the purely psychological point of 
view, too, a study of mental disorders is essential before the laws of mind 
will ever be properly understood. Pathological change always throws 
light on physiological function. 

It has always been one of the great hopes of those who are interested 
in the prevention of mental disease, that a more thorough knowledge of 
its nature and treatment, and an extension of the knoAvledge we at 
present possess among the medical profession, would lead to a diminution 
of its total amount. If the brains that by inheritance had a tendency to 
this disease could be subjected during their development and education to 
the right sort of hygienic and preventive influences, beyond all doubt we 
should have less of the disease in the world. If, during matured life, 
those same brains could be made to avoid the exciting causes of the dis- 
ease, this would certainly still further lessen the evil. If educated 
medical knowledge were brought to bear on tlie customs of our civiliza- 
tion to secure tliat they are consistent with brain health, much might be 
hoped for; and, lastly, if the first signs that betoken danger to the mind 
health were observed, and the first symptoms of disease noticed, and 
their true significance apprehended, every physician in ])ractico kuinvs 
that their further onset and progress could often be arrested. 1 do not 
say that our knowledge of brain function in its large aspect, and the 



38 CLINICAL STUDY *0F MENTAL DISEASES. 

influences that affect it in the individual or the family, are as yet mature 
enough to do all these things; but how shall we know if we do not 
study ? And are not many minds better than a few, and more likely to 
obtain fuller knowledge of the matter? There is a curious sort of morbid 
delicacy, too, in the public mind about the matter, which often prevents 
a man, when he feels his mental balance insecure, from consulting his 
doctor. That abominable and cruel phase of public sentiment, which con- 
nects shame and disgrace with mental disease, does an immense amount 
of harm to individuals and to society, and our profession should by all 
means fight against it. That this prejudice of the Middle Ages should 
exist at all, is the strongest proof of the general ignorance of the matter. 
Except our profession makes the study of mental disease more general, 
we shall never be able fully to combat and overcome this most injurious 
public feeling, because it is only by professional and scientific study that 
we get over the ideas of repulsiveness to many facts of nature. It was 
only when they were scientifically studied that surgery and midwifery 
overcame the ancient prejudices against them. 

The first thing the physician in his capacity of medical psychologist 
has to do, is to form in his own mind a standard of health. And to do 
this he has to go to nature. He can no more do it from books than he 
can form a conception of the healthy breathing or heart sounds from 
books. He has to do with man as he exists in nature in all the stages of 
his mental development. No ideal man as he ought to be will suit his 
purposes. If he adopted such a standard, he would be inclined to look 
on very many of the people he met out of sorts mentally, and fit for 
segregation from their fellows. He cannot, like the clergyman, go to his 
Scriptures or his Church and find his ideal; he cannot look on man as 
A Mind or A Soul, with a troublesome body attached ; he cannot shut 
the roads to his senses, and construct out of his subjective knowledge the 
man or the mind that is to be of service to him for comparison ; he can- 
not even look on him as a bundle of faculties, feelings, and potentialities 
tied together with the small cord of life. His method of study must be 
the physiological method, assisted, as far as they can be depended upon, 
by his own subjective experiences and those of his patients. How is the 
function of sensation studied ? By accurate and scientific observation as 
to the parts of the body where it is present, by measurements of the 
degree in which it resides in different organs, by examination into the 
nerves that convey peripheral impressions to the brain, how they end in 
the tissues, where they go to in the cord and in the brain. In this 
investigation the subjective sensations of the patient are essential; but 
could we ever have had any real scientific knowledge of the function of 
sensation had we trusted to this alone? Animals cannot express their 
sensations in words, and yet where would our knowledge have been, had 
not Sir Charles Bell been able, by experiment on animals and otherwise, 
to demonstrate that there are distinct sets of nerves for sensation and 
motion? And how incomplete would have been our knowledge, how 
helpless our therapeutics, if the function had not been studied in its 
conditions of loss, diminution, exaltation, and alteration in disease! 
Just so it is with the function of mentalization. Whatever our philo- 
sophical or religious beliefs may be in regard to the Ego and the soul, 



CLINICAL STUDY OF MENTAL DISEASES. 39 

however strongly we may feel ourselves pressed on the horns of the 
dilemma that to feel implies a personality, and that as yet physiology 
has not devised any hypothesis by which we can even conceive person- 
ality as a brain function — in spite of this, we must, when we come to 
study and treat patients whose mental functions are deranged, go on the 
hypothesis that mentalization is a brain function as much as sensation or 
motion. 

The student of mind from this point of view is met on the very 
threshold by the obvious fact, that it differs enormously in its normal 
manifestations in different persons and sexes, in different stages of life, 
and in different races. He sees, too, that it is manifestly influenced by 
the other functions of the organism, and the organs through which those 
functions are performed. These facts prepare him to accept to some 
degree, at least, the generalizations that previous students of the subject 
have made as to the existence of different mental types associated with 
bodily characteristics, or the doctrine of temperaments and diatheses. 
He sees, for example, that there are certain persons in whom the nervous 
functions are very active, and seem specially to dominate the other func- 
tions. Such persons feel keenly, move quickly, and think clearly, these 
qualities being impressed on the form, contour, and nutrition of the 
whole body. He soon comes to observe that persons with such a neurotic 
diathesis are liable to diseases special to themselves, and that when they 
suffer from ordinary diseases, the neurotic predominance in their consti- 
tutions often affects the character and duration of such diseases. No 
physician of experience but knows that neuralgias, hysteria, paralysis, 
and convulsions are more common among persons of this type and their 
children than among the general population. It is a well-known fact 
that in certain cases of this type, acute rheumatism, for instance, will 
attack the brain and cord, producing coma or chorea, and that even the 
syphilitic poison will by preference attack the neuroglia rather than the 
joints in such neurotic constitutions, and that when such people suffer 
from fevers they are more apt to be delirious. 

The facts of nature compel the physician to see that purely mental 
qualities and mental defects are transmissible from parent to child, and 
prepare him for the great part that heredity plays in psychological 
development and in mental disease. It has not yet been proved statisti- 
cally Avhether the shape of a man's nose or the acuteness of his moral 
sense is most apt to be transmitted to his children or grandchildren, but 
I am strongly of opinion that the latter will be found to be so. 

The medico-psychological student finds that, in addition to the influ- 
ence of temperament, diatheses, and heredity, the working of mind in 
each individual is influenced daily by other organs than the brain. He 
finds the so-called animal and organic functions and propensities so inter- 
woven with the purely mental functions, such interaction and reaction 
between them all, that he instinctively forms the conclusion and acts on 
it, that he must look on the whole man — body, mind, and spirit — from 
the point of view of an organism wliose wliole needs and capacities 
exhibit unity and solidarity throughout. Take, for instance, the function 
of alimentation. No doubt the swallowing, digestion, and absorption arc 
chiefly mechanical and chemical processes, performed in a living labora- 



40 CLINICAL STUDY OF MENTAL DISEASES. 

tory, and take place in the nerveless amoeba, yet lie would be but a blind 
and narrow-sighted observer who failed to see the enormous mental and 
moral influence that the desire for food, the appetite for food, and the 
varied joleasures, organic and conscious, that suitable food produces. He 
"would soon in his practice meet with cases Avhere in rational men a badly 
cooked dinner made life not worth having to themselves, and a torment 
to those about them. And a wider view Avould show that different kinds 
of foods affected the mental development of whole races of men ; that the 
desire to get certain coveted foods stimulated the highest ingenuity and 
thinking power of the wisest of men, while the Avant or poverty of food 
had made civilized men into wild beasts, as during the French Revolution, 
or among shipwrecked sailors. The absolute dependence of the appetite 
for food on brain and ganglionic integrity and sound working is so often 
seen by physicians, that they need no physiological proof that the appe- 
tite is a brain function. "What stops the appetite at once when sudden 
fear or joy is felt ? Through what organ is it perverted during pregnancy 
or in hysteria ? What stimulates it to ravenousness in diabetes, if it is 
not a brain function ? 

Take a function still more nearly affecting mentalization, that of the 
reproduction of the species. What i:)ractical student of mind can disre- 
gard it ? What physician can overlook the part it plays ? How directly 
it influences the whole affective life and history of mankind ! How the 
ascetic religionists of all creeds, with ideal a priori standards of life 
before them, have striven to set themselves free from its influence on their 
minds and lives I AYhat attempts have been made to degrade it into 
something almost criminal and bruitish in one age, to ignore it in the 
next, and to idealize it in the next ! The psychological physician must 
simply accept the facts of physiology, and regard man as a whole, mind 
and body. So regarding him, he is every day beset with problems that 
imply consideration of the reproductive functions of the human species, 
and their effects direct and indirect on the minds of his patients. And 
the sooner he begins to regard the whole matter from the physiological 
and professional point of view, just as the obstetrician does his work, the 
better for himself and his patients. It will often need all his physio- 
logical knowledge and his psychological study, combined with his com- 
mon sense and general knowledge of human nature, to expiscate the 
mental sympathies and aversions, the reflex and sympathetic irritations 
and impulses, and the paralyzed volitions of some of his adolescent, hys- 
terical, puerperal, celibate, and climacteric patients. 

A knoAvledge of the enormous variety of mental types seen in nature 
will effectually prevent the physician from setting up a Utopian and flilse 
ideal standard Avith which to compare deranged mind when he comes to 
study that subject. It is of the utmost practical importance that it should 
be so. Those students who attend my clinical lectures will find that there 
are few questions I shall so often ask as this — "What sort of man was 
this when he was reckoned well in mind?" "How does he now differ 
from his state then?" "Are his present mental peculiarities evolutions 
of his temperament?" "Are they connected with his diathesis?" 
"What is the exact nature of the mental disturbances present?" "Is 
the judging, the feeling, the controlling, the resistive powers, the memory, 



CLINICAL STUDY OF MENTAL DISEASES. 41 

or the imagination aifected? and if so, in what degrees and ways ? " "Is 
there general mental exaltation, depression, or enfeeblement present?" 
"Are the mental symptoms fixed or changing ? " "Is the sleep function 
interfered with?" "Do those disturbances bear relation to any disturb- 
ance of the great functions of the body ? " " What bodily functions are 
disordered along with the mental?" "Are there any purely bodily 
symptoms present?" "Was the onset of the mental disease connected 
with any functional evolution such as puberty, with any ordinary physio- 
logical process such as menstruation, or with any extraordinary physio- 
logical cataclasm such as childbirth?" "Are any of the other great 
functions of the nervous centres, such as motion or sensibility, impaired ? 
and if so, w^hether primarily or secondarily to the disordered mentaliza- 
tion ? ' ' This is the clinical mode of studying mental disease, founded 
on a physiological basis. It implies something far more than merely 
classifying the mental symptoms of your patients, and ticketing the 
various groups with a name. You can easily imagine the same mental 
symptoms to exist, and, as a matter of fact, they very often do exist, in a 
girl of fifteen entering on puberty and in a puerperal woman, but in the 
latter case the bodily symptoms would be quite different from the former, 
the temperature perhaps being 103°, the lochia absent, the tongue dry, 
the pulse feeble, the uterus septic and irritated, and the general condition 
so weak that a few more steps downward would lead to death ; while in 
the former the strength would be good, the pulse good, and the tempera- 
ture almost normal. Both cases, looked at from the point of view of 
mental symptoms, would be called acute mania, and yet they would be 
quite different in etiology, in bodily symptoms, in prognosis, and in 
treatment. 

The proper point from which to start in studying diseased mentaliza- 
tion being the normal physiological energy of the brain, and a recogni- 
tion of the fact that the normal type is not a fixed point or line, but a 
wide area with far diverging promontories according to age, sex, race, 
education, period of life, heredity, diathesis, and temperament, we next 
come to the question of how far mere temporary causes, such as changes 
in the blood supply, excesses of work, strains of all kinds, or reflex irrita- 
tions, affect the mental energy of the brain, but still keep within a line 
that may be, and ought to be, reckoned physiological. If a man works 
till he cannot any longer lift his arm, we do not call it paralysis ; if he 
sleeps so soundly afterwards that no ordinary stimuli will awake him, we 
do not call it coma : Ave place neither condition out of the physiological 
into the pathological state. So, if a man's heart is made glad by wine 
or by extraordinary good ncAVS, and he shows many signs of mental exal- 
tation unusual in him, or if he loses blood or has bad news, and is pro- 
foundly depressed, we still call those states plij^siological, and do not 
count them pathological mentalization at all. A num's power of judging 
and comparing, his emotional condition, his inhibitory power, may all be 
so far paralyzed as to be in abeyance for the time, and yet ayo may count 
him perfectly free from mental disease. Nay, I have seen two men in 
exactly the same condition for the time being, so far as mental sym})toms 
were concerned, and I counted the one sane and the other insane. Wlion 
the limits of the physiological are passed, aiul a man enters on a patho- 



42 CLINICAL STUDY OF MENTAL DISEASES. 

logical state of mind, we are often utterly unable to tell the exact line 
where the one ends and the other begins. As Maudsley says, you might 
as well attempt to draw the line between light and darkness. There is no 
rubicon over which a man passes from the one into the other. Insanity 
does not enter into a man at one door, while sanity departs at the other. 
That fact you should never forget, any more than the fact (to take one 
of the most definite ascertainable physical conditions of the human body) 
that you can never tell where a normal temperature ends and an abnor- 
mal one beo-ins. You know that 98° is within the limits of abnormal 

o 

physiological heat. You know that 108° is abnormal and pathological, 
but you cannot tell at w^hat point health passes into disease. 

For the study of mental disorders, w^hile the general state of mind must 
be the same as that in which we study ordinary bodily diseases, w^hile it 
is essentially the clinical faculties that we put into exercise, yet there 
needs to be superadded a different kind of design and conscious effort to 
find out what the morbid symptoms are, more of comparison with health, 
more scepticism as to what the patient says directly about his own symp- 
toms, and far more strain in the effort to draw out the patient into a 
veracious and open state of mind. The constant effort to interpret 
the clinical meanings of subtle changes in your patient's manner, and 
the significance of what he says and how he says it, is wearying ; while 
the difficulties of delicately leading him over the ground where his mental 
deficiencies exist are often excessively great. His every w^ord and act 
must be closely scrutinized, for they form part of the symptoms on which 
your diagnosis rests. An initial difficulty with the uninstructed is in the 
want of terms to express the mental symptoms. I have heard a man 
try to describe the symptoms of an ordinary case of acute delirious 
mania to me, and utterly fail to give any connected idea of the patient's 
state. Such a description as this I have often got: "He won't do any- 
thing you tell him. I can't make anything of him. He talks a lot 
of nonsense. He's just mad." 

Though our nomenclature for the deviations from normal mentalization 
is as yet unscientific and incomplete, and must one of these days be 
revised, yet most abnormalities are capable of being in some way de- 
scribed or indicated. The common symptoms met with have been classi- 
fied, and form the first classification of mental diseases to which I shall 
direct your attention. It is in reality only a classification of symptoms, 
not of real diseases, but the symptoms are most important and are the 
first things to be observed. The nomenclature this classification gives us 
is quite essential for our study of disordered mind, and its terms have 
become current in medicine, jurisprudence, and general literature. 
Pinel's and Esquirol's original classification of mental diseases on this 
principle has undergone many modifications and extensions, and I, like 
my predecessors, have introduced some changes. The principles on 
which it is founded are, to take one example, that all the states of 
morbid mental depression and painful feeling are classed under one head. 
Melancholia, just as all the painful disorders of sensibility are called 
Neuralgia. Indeed the melancholias bear a close analogy to the neural- 
gias. In the one case the mental functions of the brain are affected, in 
the other the common sensibility. Most cases of melancholia might be 



CLINICAL STUDY OF MENTAL DISEASES. 4S 

called mental pain. Indeed, it would be more scientifically called Psy- 
chalgia. 

Then all the states of morbid mental exaltation and excitement are 
classed together and called Mania, just as the motor storms and explo- 
sions are called convulsions, eclampsias, epilepsies, or spasms. A typical 
case of mania may be considered like a mental chorea or eclampsia. 
There is present disordered, incoherent, involuntary, purposeless mental- 
ization. Mania might be called Psychlampsia, if we wanted to set up a 
more uniform nomenclature than we have at present. 

There are other cases whose symptoms consist of regularly alternating 
mental states, usually of depression and exaltation, this rhythmical 
recurrence of mental pain and spasm going on during the whole course 
of the disease, and constituting its essential distinctive character. I 
think a better name for this than the one given to it by Baillarger, who 
first described it, viz., Folie Circulaire^ would be Alternating Insanity. 
Though only described as a variety of mania by him, yet I think its 
characters are so distinctive as to vindicate for it a special place in a 
complete symptomatological nosology, which I have accordingly given it. 

The fixed delusional states without excitement or depression come 
next, the Monomanias. Just as we now separate the monospasms and 
the local convulsions from the general eclampsias, I think it is better to 
place the cases of monomania by themselves, instead of calling them, as 
some authors do, partial mania. Monomania is analogous to a parass- 
thesia, being in fact very often due to a want of correspondence between 
the impression received by the brain from the special senses and the real 
objective impressions that have been made on them, through their getting 
distorted on their way from the organs of sense to the convolutions. For 
instance, if a man hears distinct articulate words which are merely the 
meanings of the wind to others, and if those subjective false voices call 
him bad names, he becomes suspicious of the people about him; this 
becomes a morbid habit of his mind, without any special excitement or 
depression, and we say he labors under monomania of suspicion. This 
is one way in which delusion may arise. A true impression from a 
nerve of common sensibility may be misinterpreted, as when a man has 
cancer of his stomach that causes him real gnawing pain, and he says he 
has rats inside him that are eating his vitals. It might help you to 
understand this condition better if it were called Monopsychosis. 

When the morbid condition is one of mental enfeeblement it is called 
Dementia or Amentia, both very good terms. The conditions they 
represent are strictly analogous to the anaesthesias, pareses, and partial 
paralyses that result Avhen the sensory and motor centres of the brain 
are respectively diseased. It might be called Psychoparesis. 

The next on the list, I have placed there because it fills up a gap that 
existed in former classifications of mental symptoms. It represents the 
negation of mental ization resulting from disease, where the patients are 
insensible to external infiuences, will not speak, Avhere the faculty of 
attention appears to be quite gone, and where they appear not to think 
or feel at all. I can devise no better name than the usual one of Stupor, 
Amentia being already appropriated to Idiocy — which, by the ^vay, is 



44 CLINICAL STUDY OF MENTAL DISEASES. 

never really mindlessness as the name would imply. " Psjcliocoma " 
would express this condition. 

Inasmuch as physiology has clearly demonstrated the existence of 
centres in the nervous system that control other nervous centres, giving 
the name of inhibition to the function of the former ; and we find that 
there are certain cases of mental disease, where an analogous function of 
the higher ideo-motor nerve-centres seems to be deranged, where there 
are, in fact, states of want of inhibitory mental power without marked 
depression, exaltation, or enfeeblement, I have put those under a special 
class, viz., states of defective mental inhibition. Those might be called, 
for the sake of keeping up a scientific correspondence in the nomenclature, 
Psychokinesia. 

Lastly, there is a mental state graphically described by Dr. Maudsley, 
and which certainly represents facts in nature, the insane temperament 
or neurosis insana, or, to keep up uniformity of the classification, Psy- 
choneurosis. This consists more of potentialities of psychosis, of extra- 
ordinary and unusual assortment of mental faculties, of states of feeling 
that are unaccountable and uncommon, and of courses of conduct that 
seem merely automatic, and incapable of volitional regulation — all these 
things being the result of a hereditary neurosis in a brain whose various 
functions and parts are unconformable, or whose dynamical constitution 
is unstable and eccentric. The following is the symptomatological classi- 
fication I shall use with the chief varieties of each form: 

1. Stites of Mental Depression (3fela7ichoIia, Psychalgid). — a. Simple 
Melancholia, h. Hypochondriacal Melancholia, c. Delusional Melan- 
cholia, d. Excited Melancholia, e. Resistive (obstinate) Melancholia. 
/. Convulsive Melancholia, g. Organic Melancholia, h. Suicidal and 
Homicidal Melancholia. 

2. States of Mental Exaltation (3Iania, Psyclilampsid). — a. Simple 
Mania, h. Acute Mania, c. Delusional Mania, d. Chronic Mania. 
e. Ephemeral Mania [Mania Transitorid), f. Homicidal Mania. 

3. States of Regularly Alternating Mental Conditions {Folie Circu- 
laire^ Psycliorythm, FoUe a Double Forme^ Circular Insanity^ Periodic 
Mania, Recurrent 3Iania, Katatonia). 

4. States of Fixed and Limited Delusion (3Ionomania, 3Iono29sychosis). 
— a. Monomania of Pride and Grandeur, b. Monomania of Unseen 
Agency, c. Monomania of Suspicion. 

5. States of Mental Enfeeblement {Dementia and Amentia^ Psycho- 
paresis, Congenital Imbecility, Idiocy). — a. Secondary (Ordinary) De- 
mentia (follo^ving 3Iania and 3Ielancholia). b. Primary Enfeeblement 
(Imbecility, Idiocy, Cretinism, the result of deficient Brain Develop- 
ment, or of Brain Disease in very early life), c. Senile Dementia. 
d. Organic Dementia {the result of gross Organic Brain Disease). 

6. States of Mental Stupor (Stupor, Psychocoma). — a. Melancholic 
Stupor, "Melancholia attonita." b. Anergic Stupor, "Primary De- 
mentia," " Dementia attonita." c. Secondar j Sti\i:>OY (transitory after 
Acute Mania). 

7. States of Defective Inhibition (Psychokinesia, Hyperkinesia, Im- 
pulsive Insanity, Volitional Insanity, Uncontrollable Impulse, Insanity 
without Delusion). — a. General Impulsiveness, b. Epileptiform Im- 



CLINICAL STUDY OF MENTAL DISEASES. 45 

pulse. c. Animal, Sexual, and Organic Impulse. d. Homicidal 
Impulse, e. Suicidal Impulse. /. Destructive Impulse, g. Dipsomania. 
Ji. Kleptomania, i. Pyromania. k. Moral Insanity. 

8. The Insane Diathesis (PsychoneurosiSj Neurosis Insana^ Neurosis 
Spasmodica). 

All these varieties of mental disease find their origin in and flow out 
of excess, defects, and irregularities in the physiological functions of the 
brain. They may all arise from innate morbid tendencies in the organ, 
or from eccentric causes within or without the organism. The brain 
responds by thought, by sympathy, by instinctive and reflex influences^ 
to almost everything in the universe outside it, and to every tissue, 
organ, and energy within the organism, and no two brains are alike in 
their reactions. If its constitution is unsound therefore, or if its conditions 
of energizing are unphysiological, the causes being innumerably various 
without and within for aberration and derangement, it results that the 
symptoms are almost as various as the causes of mental disease. More 
than of any other disease, it may be said that no one ever saw two cases 
precisely alike. This or any other classification, therefore, only represents 
types and genera, not species. 

Such was until recently the usual mode of studying and classifying 
mental diseases. It assumes that the mental symptoms are the chief 
things about the disease to be observed. The late Dr. Skae, following 
Morel and Schroeder van der Kolk, devised and directed special atten- 
tion to another mode of looking at mental disease, which we may call 
the clinical method. It endeavors to take account of causes, and of the 
relationship the diff"erent varieties of the disease have to the great physi- 
ological periods of life, and to the activities of the body other than the 
mental — in other words, it regards the whole natural history of the dis- 
eases. 

The chief varieties of this clinical classification (which includes the 
pathological varieties of mental disease) are the following : 

1. General Paralysis. 2. Paralytic Insanity (^Organic Dementia), 
3. Traumatic Insanity. 4. Epileptic Insanity. 5. Syphilitic Insanity. 
6. Alcoholic (and Toxic) Insanity. 7. Rheumatic and Choreic Insanity. 
8. Gouty (Podagrous) Insanity. 9. Phthisical Insanity. 10. Uterine 
Insanity. 11. Ovarian Insanity. 12. Hysterical Insanity. 13. Mas- 
turbational Insanity. 14. Puerperal Insanity. 15. Lactational In- 
sanity. 16. Insanity of Pregnancy. 17. Insanity of Puberty and 
Adolescence. 18. Climacteric Insanity. 19. Senile Insanity. 

There are a number of more rare and less important varieties of in- 
sanity, Avhich I shall just allude to, viz. : 

1. Anaemic Insanity. 2. Diabetic Insanity. 3. Insanity from 
Bright's Disease. 4. The Insanity of Oxaluria and Phosphaturia. 
5. The Insanity of Cyanosis from Bronchitis, Cardiac Disease, and 
Asthma. 6. Metastatic Insanity. 7. Post-Febrile Insanity. 8. In- 
sanity from Deprivation of the Senses. 9. The Insanity of Myxanlema. 
10. The Insanity of Exophthalmic Goitre. 11. The Delirium of Young- 
Children. 12. The Insanity of Lead Poisoning. 13. Post-Connubial 
Insanity. 14. The Pseudo-Insanity of Somnambulism : 

In studying mental diseases, one must constantly refer to the general 



46 



CLINICAL STUDY OF MENTAL DISEASES. 



functions of the brain, and I have thought it might be useful to point 
out, in the following form, the bearings of some of the most important 
anatomical, physiological, psychological, and pathological considerations 
on that study : 



There is in the brain an extreme com- 
plexity of tissues, fibres, and groupings, 
and an extreme delicac}^ of structure, 
these corresponding, no doubt, to the 
multiformity, complexity, and delicacy of 
its functions. There is an obvious inter- 
dependence of parts, and a localization of 
structures and functions, but yet a real 
solidarity of the whole brain in structure 
and function. 

There is- the most direct connection, 
structurally and functional!}", of every 
organ and of every tissue with the brain 
convolutions, and their influence is mu- 
tual, powerful, and constant. 

Developmentally and functionally one 
nervous ganglion or group of cells is 
''higher" than another, and controls or 
stops its action. 

Looking at a brain convolution, its 
nerve cells differ in shape and size. The}'- 
are placed in distinct layers, and arranged 
in groups. They have been demonstrated 
to be different in appearance in young 
children, in idiots, in old persons, and in 
many cases of insanity, from what they 
are in a health v adult (see Plate VIII., 
Figs. 2, 3, and 4). 

There is reason to suppose that many 
parts of the brain convolutions can ener- 
gize in different ways, one part being 
capable of doing the work ordinarily 
done by another ; and every part of the 
brain is double. 

The brain has a reflex and automatic 
action. Most of its functions are affected 
by this, and may be excited into activity 
or may be disturbed in a reflex manner 
by indirect stimuli, like the heart from 
stomach derangement. Most of the re- 
flex functions of the brain may be unat- 
tended by consciousness; or conscious- 
ness without volition may be present in 
regard to mental acts and to subsequent 
muscular action. 

The study of the physiological condi- 
tions of sleep, dreaming, and hypnotism, 
are most important, though as yet many 
of the phenomena are very obscure. 

Consciousness ma}" be complete, par- 
tial, or abolished in health. 

The brain has fixed limits of energiz- 
ins: in all directions. 



All sorts of sensations, we must keep 
in mind, are subjective, and depend on 



Hence we are apt to have many func- 
tions and structures involved in mental 
diseases — motor, sensory, vaso-motor, and 
trophic. Localization is never complete, 
and solidarity is never perfect. 



Hence peripheral lesions and disor- 
dered functions of organs cause mental 
disturbance, and vice versa. 



Hence disorder of the higher centres is 
far more important than of the lower. 



Hence we have a structural basis for 
certain forms of insanity, and for limited 
mental affections. 



If this is so, damage to, or exhaustion 
of, one portion of brain convolutions [as 
in Goltz's and Nothnagel's experiments], 
need not necessarily cause irretrievable 
loss of mental functions. 

In mental disease, this reflex function 
of the brain plays a most important part. 
Many symptoms can only be rightly ex- 
plained through it. In many mental 
diseases the brain acts automatically, even 
suicidal and homicidal impulses taking 
place, the volition and the consciousness 
beino: absent. 



The psychological facts of those condi- 
tions should be kept in mind in studying 
mental disease. No phenomena of the 
latter are more obscure than those of the 
former. 

In mental disease we see those condi- 
tions from pathological causes. 

Hence the danger of causing disturb- 
ance or paralysis of function by coming 
too near those limits, or overstepping 
them. 

Sensations can be misinterpreted, there- 
fore, in mental diseases, and, as a matter 



CLINICAL STUDY OF MENTAL DISEASES. 



47 



consciousness. The real import of most 
sensations, special and common, was 
originally only learned slowly and by in- 
terpretation and experience in childhood. 
There is a tendency in the brain to 
propagation, diffusion, and extension of 
action, normal and abnormal, and there 
is much trophic solidarity in the whole 
brain, its envelopes, and the nerves con- 
nected with it, quite independently of 
whether the tissues are cellular or fibrous, 
or whether the function is originating or 
conducting. 



Every mental manifestation, normal 
or abnormal, must be assumed to take 
place directly through the energizing of 
the brain convolutions. 



Mentalization differs so enormously in 
degree, form, and intensity in different 
human beings, in the two sexes, and in 
different races, and at different ages, that 
any correct standard of mental health 
must allow an enormous margin of psy- 
chological difference, apart altogether 
from disease. 

The action of "mind on mind" in 
healthy brains is direct, intense, and most 
subtle. 

The quality, the power of energizing 
and of resistance, the mode of working, 
the liability to disease, and the recupera- 
tive power of the convolutional brain 
tissue, are probably determined more 
largely in any individual by his heredity 
than by any other cause. Bad heredity 
may affect the whole brain and all its 
functions, or only a part of them. 

The chief of the human instincts, appe- 
tites, and organic necessities are — 

1. Love of life, with efforts to prolong 
it. 

2. Desire to reproduce the species. 

3. Love of offjpiing, with efforts to 
nourish and protect it. 

4 Social instincts in innumerable 
forms. 

5. Necessity to energize. 

6. Appetite for food and drink. 
Many of these are periodic in their in- 
tensity or occurrence. 

The chief faculties, looked at from the 
mental point of view, are consciousness, 
perception, ideation and judgment, voli- 
tion and mental inliihilion, affective fac- 
ulty or all that lelates to feeling and 
emotion, memory, power of attention, re- 
presentation and imagination, association 
of ideas, and si)eecli. 



of fact, many insane delusions arise in 
that way. 



This takes place abnormally in disor- 
dered working of the organ, disordered 
functional conditions extending from the 
encephalic tissue regulating one function 
to that regulating others. There is a 
strong tendency to ]-)rogressive patholog- 
ical propagation of diseased processes in 
the brain and along the nerves. Many 
forms of insanity are, no doubt, explained 
in this way. Usually the functional 
propagations, like the structural degen- 
erations, take place in the line of physio- 
logical function. 

Hence, wherever the "origin " of men- 
tal disease may be, or whatever may be 
its "causes," mental or physical, its im- 
mediate cause and seat must be in the 
disordered energizing of the brain con- 
volutions. 

Hence the necessity for special inquiry 
as to the normal mental power, the nor- 
mal mode of working, the temperament 
and the diathesis in every case of mental 
diseases one has to study or treat. 



The same is the case when the brain is 
disordered, and hence in psychiatry men- 
tal therapeutics are a most important 
nir-ans of treatment. 

Hence the importance of a study of 
heredity in mental disease. In some 
form, direct or indirect, it is rarely ab- 
sent in any case. 



In every case of insanit}^, attention and 
inquiry must be directed as to whether 
any of these are impaired, paralyzed, or 
perverted, or whether their normal peri- 
odicity is interfered with. 



It is important in examining a case of 
mental disease to go over these systemat- 
ically and test how they are affected, be- 
cause they are affected in different ways 
and degrees in dilferent cases. 



48 



CLINICAL STUDY OF MEXTAL DISEASES, 



The great physiological periods or crises 
of life (dentition, puberty, adolescence, 
the climacteric, and senility), and the 
great reproductive activities (menstrua- 
tion, ovulation, coitus, pregnancy, nurs- 
ing and care of children), bring into in- 
tense activity, or throw out of action 
wholly or partially, great tracts of con- 
volutional brain tissue. 

Diseased or undeveloped function is 
apt to be folk wed by ati-ophied structure, 
and prolonged disturbance of function by 
change of structure. 

The mode of energizing of nervous tis- 
sue is normally spasmodic, and even ex|»lo- 
sive, in regard to certain functions. This 
quality is especially developed in badly 
consiituted brains. There is reason to 
suppose that only comparatively limited 
portions of the brain can be in action at 
the same time, and that even the whole 
of the neurine tissue subserving the same 
limited function does not all come into 
activity at once. 

The blood supply of the brain is enor- 
mous (one-fifth of whole body), and of 
the gray matter of the convolutions five 
times the amount of the white. The 
gra}' matter needs, and uses up, far more 
blood than any other tissue in the body 
in proportion to its bulk. The vascular 
supply of the brain is derived from dif- 
ferent sources. The whole encephalon is 
divided more or less into vascular areas, 
each area having slight anastomosis with 
its surrounding areas. It is not yet 
proved, but it is probable, that those areas 
are co-related to different functions. The 
whole conditions of the blood su[)ply to 
the brain and within the head, are pecu- 
liar and diflferent from any other part of 
the body from its being in a shut box not 
subjected to the pressure of the atmos- 
phere, except through the vascular open- 
ings and foramen magnum, and from its 
peculiar relation to the cerebro-spinal 
fluid. The lymphatic spaces are also 
peculiar in the brain, and no doubt aifect 
its circulation and nutrition. The vessels 
of the brain, large and small, are delicate, 
have little support but the pressure of a 
shifting fluid ; and the cardiac and vas- 
cular pressure and tension are constantly 
varying. It would seem as if mental 
emotions had a more direct and powerful 
influence on the vessels of the head than 
on those of almost any other part of the 
body, e. g.^ m blushing, etc. 

The various envelopes, protecting, and 
packing tissues of the brain, are most im- 
portantin themselves and in their normal 
relationship to the brain. They deiive 
their blood supply from the same sources. 



Hence these are very apt to be attended 
with danger to the normal mental bal- 
ance when the convolutional tissue is bad 
in quality, unstable, or badly nourished, 
or specially liable to morbid explosions of 
energizing. In every case of mental dis- 
ease the possible influence of these should 
be inquired into. 

Hence prolonged mental enfeeblement 
is followed by brain atrophy and pro- 
longed mental disturbance by structural 
brain changes. 

This explains in some degree the phe- 
nomena of mental morbid explosions and 
fimctional defects being suddenly devel- 
oped when the structural cause has been 
a gradually advancing one, e. g.^ we see 
sudden mania, or paralysis, or convul- 
sion, or unconsciousness resulting from 
softenings or sclerosis, or inflammation, 
that have been going on gradually for a 
long time till they reached a certain point 
beyond which function could not be per- 
formed. 

Hence, when in certain forms of men- 
tal disease there is congestion or vaso- 
mot'^r dilatation of those already crowded 
capillaries, we have serious effects on the 
neurine and its functions. Nothing is 
more common after death in insanity 
than to find the brain substance divided 
into distinct vascular and ansemic areas 
(Plate II.). Certain morbid appearances 
(e. g.^ " pachymeningitis hfemorrhagica 
interna") are found within the skull, 
which are not found elsewhere at all. 
The lymphatic spaces are often found 
blocked up by debris. Capillary hemor- 
rhages (Plate yil., Fig. 2) are most com- 
mon in insanitv, and vascular disease is 
most common, and should always be 
looked for, in those who die mentally 
affected. 



In mental disease we often find more 
evident and constant disease in the bones, 
membranes, neuroglia, and epithelial lin- 
ings of the ventricles than in the brain 
itself. When diseased they affect the neu- 
rine secondarilv, or are affected by its dis- 
eases (see Plates IV. and VII., Figs. 1, 2). 



CLINICAL STUDY OF MENTAL DISEASES. 49 

It may be said generally that inflam- Hence we must specially examine those 

mation and new pathological formations packing and vascular tissues, and we 

— tubercle, syphilis, cancer, etc. — show a often find that though they are affected 

greater affinity for the packing tissues primarily by those new pathological for- 

and bloodvessels than for the brain itself, mations, yet the neurine has suffered as 

while the progressive degenerations tend much, structurally and functionally, as if 

more to affect the true nerve tissue. it had been first affected. 

As to the general method of clinically examining a patient, insane or 
supposed to be insane, the following rules may be of service: 

1. Get all the information about him you can beforehand, and from 
the most direct sources, especially on the following points: his heredity, 
temperament, habits, and what sort of man he was, and what delusions 
he labors under, how he is changed from his former self, whether he is 
morbidly suspicious and will resent a medical examination, whether he is 
suicidal or dangerous, whether his power of self-control is affected and in 
what way, and his weak points mentally — get, in fact, a good concise 
history of his case, especially noting the first symptoms and the general 
course. 

. 2. In your interviews be in manner natural, frank, honest, fearless, 
sympathetic, and a good listener, assuming outwardly that your patient 
is sane. Do not be afraid to lead up to his delusions and mental weak 
points after you have gained his confidence and interest. Do not con- 
tradict or irritate until you want to test his self-control. Do not deceive 
him if possible. After you have satisfied yourself he is ill, try and 
make him believe it too. Take time ; few satisfactory first examinations 
can be conducted in a hurry. 

3. Look on his speech, manner, and appearance as being, in them- 
selves, possible symptoms of his disease; be all the time in a quiet sys- 
tematic way, unobserved by the patient, testing his mental faculties (see 
p. 47) seriatim in your own mind, and be on the look-out for insane 
delusions or suspicions, depression of mind, exaltation, enfeeblement, 
lethargy and stupor, or altered feeling towards relatives and friends. 

4. Note carefully the expression of face and eyes, the articulation, the 
manner, the muscular movements, the writing if possible, the nutrition 
of the body and the conformation of head. 

5. Examine the state of the pulse and temperature. Never think any 
examination complete without taking the temperature. Many patients 
laboring under the delirium of fevers and inflammations would have been 
saved from being sent to asylums had this been done. Examine into the 
condition of tongue, appetite, digestion, bowels, and, in fact, go over all 
the great bodily functions. Especially find out about the sleep — whether 
he sleeps at all, what kind of sleep, and for how long, and whether he 
dreams, and of what character the dreams are; usually the sleep is 
"broken "and unrestful in the early stages of insanity, the patients 
dream much, and the dreams are unpleasant. Examine into tlie motor 
and sensory functions of the brain and cord, especially asking about 
lieadaches and neuralgic pains. Always remember that the ordinary 
symptoms of bodily disease may be masked by the brain condition, so 
that lung and visceral diseases, injuries, etc., may exist without any con- 
sciousness of the patient or any obvious sym])toui whatever. 

4 



50 CLINICAL STUDY OF MENTAL DISEASES. 

6. Remember there are three aspects to every case of insanity — the 
medical, which concerns you as a physician about to treat a patient; the 
medico-legal, which concerns you and the patient in regard to depriving 
him of his liberty and of the control of his affairs, and affects his respon- 
sibility to the law; and the medico-psychological, which includes all the 
mental problems that arise in a study of the case. 

7. Always pass before your minds the following conditions, and by 
exclusion determine that the case is not one of them, viz., drunkenness, 
drugging by opium or other narcotics, meningitis, cerebritis, brain syphilis, 
the fevers, sunstroke, traumatic injury to head, hysteria, the cerebral 
effects of gross brain diseases, simple delirium tremens, the temporary 
cerebral effect of moral shock, or the delirium that precedes death in 
many diseases and in old age. I have had cases of drunkenness, menin- 
gitis, typhus and typhoid fevers, hysteria, apoplexy, delirium tremens, 
and the delirium preceding death, sent into asylums under my care, as 
laboring under ordinary insanity, and have heard of the other conditions 
being so mistaken. Many of these conditions and diseases may, how- 
ever, lead to, or be associated with, real mental disease, and require 
treatment as such. 

8. In the clinical study of mental diseases, tvj and look on all the 
abnormalities present, mental and bodily, as being symptoms of the dis- 
ease, and essential parts of the brain disturbance present, and not as 
mere accompaniments. For instance, in a case of puerperal insanity, it 
is not merely the delusions and mental exaltation that are the disease, 
but the high weak pulse, the raised temperature, the glistening eye, the 
constant muscular motion, the dry tongue, the uterine tenderness, the 
absence of lochia, the sleeplessness, the paralyds of appetite, are all 
symptoms of the disease in a true sense — that is, they are all results or 
essential concomitants of the brain disturbance, of which the mental 
symptoms are the most striking features. 

9. The patient's account of himself is not always to be relied on. He 
may be dying, and yet to his consciousness have no symptom of it, so 
that he tells you he never was better in his life; his bowels may have 
been moved freely that morning, and yet he tells you he has not had a 
motion for a week ; he may not be able to write a line, yet he says he 
never wrote so well in his life, etc. You must, through your reasoning, 
medical examination, and observation, find out what is true and what is 
delusion. I had once a case where a medical man certified as a delusion 
what an examination would have shown him to be a fact, viz., tliat the 
patient was pregnant. Certain things of the greatest import in a case of 
insanity the patient is very apt to deny, such as suicidal feelings, mastur- 
bation, etc. 

10. It may be needful in some cases for the patient's safety, or that of 
his relations, or for the preservation of his property, to practise some 
amount of concealment of your profession, and of the object of your visit. 
The man knows so well what a doctor's visit means that he will not see 
a doctor if he knows him to be one, or he is so dangerous and cunning 
that needless risk would be run by announcing to him the object of your 
visit. But the public and the friends of patients have often a most 



CLINICAL STUDY OF MENTAL DISEASES. 51 

needless desire that you should practise guile where there is no necessity 
in the world for it. As a general rule, there is not much to fear from 
the insane of the respectable classes of society. But cunning and sus- 
picion are the marked characteristics of many of those affected in mind. 

11. Negative symptoms — silence, obstinacy, stupidity, etc. — are to be 
noted and are valuable in diagnosis and treatment. , 

12. Compare mentally the man as you see him with the man you may 
have known or had described to you. 

13. The chief questions you ask yourself, and the main problems that 
you have to solve, are the following : Is the man mentally affected or 
not ? If so, is he sufficiently affected to be regarded as legally insane 
and irresponsible ? What form of insanity does he labor under ? Can 
the brain disease be localized or its pathological character determined ? 
What is to be the treatment ? What risks are there in the case, e. g.^ of 
suicide, danger to others, convulsions, paralytic attacks, exhaustion, 
refusal of food, or sudden death ? W^hat is the general prognosis ? How 
long will it be before the case recovers or dies ? Is home treatment 
suitable or safe? or must the case be removed from home to the country, 
or to a hospital for the insane ? Can trained reliable attendance be got ? 
What mental therapeutics must be adopted, cheering or soothing, divert- 
ing, reassuring, checking, agreeing with him, contradicting him, or avoid- 
ing his favorite topics ? 

14. It is always well, in a case of mental disease, to make the relations 
or guardians of the patient very fully acquainted with the risks of the 
case, to keep them hopeful if there is any hope, to give the patient the 
benefit of all doubts, to guard yourself in prognosis, remembering that 
our knowledge of mental disease is imperfect, and that the most experi- 
enced of us are deceived sometimes, and that there are few rules in regard 
to brain disorders to which there are not exceptions, to take no more re- 
sponsibility about sending a patient to an asylum, for instance, than 
fairly can be laid on a medical man, making the relatives take their 
proper share. It is, as a general rule, better not to be too explicit about 
the time it may take a patient to recover. If you undertake the treat- 
ment at home, or in a private house, only do so on the understanding 
that the nurses or attendants are under your exclusive orders. If you 
have to sign a certificate of insanity for placing a patient in an asylum, 
or taking the management of his affairs out of his hands, remember there 
is often a legal risk to yourself from the patient bringing an action against 
you, a risk that in some rare cases it is well to avoid by even getting a 
letter of indemnification from a relation before you sign it. 

15. In regard to the question of home or as^dum treatment, it depends 
on many other things as well as the patient's condition. His means are 
the first of these. Home or private house treatment of a case of mental 
disease is mostly expensive from the skilled attendance needed. In the 
midst of a city, home treatment of almost any case is most difficult. 
Home treatment is often impossible from the associations and surround- 
ings aggravating the disease. If there is a very intense suicidal tendency, 
the risks cannot well be obviated in a private house. If there is noise, 
maniacal excitement, or constant muscular motion, a private house is 



52 CLINICAL STUDY OF MENTAL DISEASES. 

seldom a proper place for long. In a good hospital for the insane, most 
of the means of treatment, safety, skilled attendance, regular exercise, a 
proper mode of life, the administration of food and medicines, can no 
doubt be best attained, but then there are the counterbalancing disadvan- 
tages of the harm to the patient's prospects, from the cruel popular pre- 
judices about asylums, and the patient's own feelings about it afterwards. 
If you can treat a case out of an asylum, and he recovers satisfactorily, 
it is better for you and him. 



LECTURE II. 

STATES OF MENTAL DEPEESSION— MELANCHOLIA {PSYCHALGIA). 

All the morbid states of depressed feeling, or, as more commonly ex- 
pressed, of mental depression, are comprised under the term Melancholia. 
Like the other symptomatological varieties of mental disease, melancholia 
does not admit of an absolutely precise definition. In every case there 
must be mental pain, hence I have suggested as an alternative the term 
Psychalgia, but then mental pain does not alone constitute melancholia. 
As man's experience goes in the world at present, mental pain scarcely 
implies the idea of disease at all. The causes and occasions of mental 
pain from within and without are so common, as most men are now con- 
stituted and situated, that its presence is the rule with many, and its 
entire absence the exception with most. To constitute melancholia there 
must be disorder of brain function. A man's finger is squeezed in a vice, 
and he feels the most intense pain, but we do not call that neuralgia. He 
loses a child or a fortune, and feels intense mental pain, but we do not call 
it melancholia, because there is no disease. All brain reactions mentally 
in obedience to adequate causes are simply the exercise of physiological 
function, but when the reaction is quite out of proportion to the cause, 
or when the exercise of the activity of the brain induces mental pain of 
a certain intensity and kind without any outside cause, then we conclude 
that the mental portion of the organ is disordered, and we say that the 
patient suffers from melancholia. There may be in the case certain ex- 
citants wrongly called causes — mental, moral, or physical. The man 
may have committed crimes, or he may have a badly acting liver, or he 
may be very anaemic, and all these things may cause mental pain and 
depression in a healthy brain, but they will not cause them in that 
amount and kind to constitute melancholia till his brain convolutions 
have taken on a disordered action — until their dynamical state is that of 
disease, not that of health. If a man's heart is depressed in its action 
from a fright, we do not give this a name implying disease, unless the 
depression goes on long after the cause has ceased to act. This illus- 
trates, too, the weak points of the method of classifying mental diseases 
from mental symptoms alone. It is as if in cardiac diseases we should 
classify them as syncopes, palpitations, and anginas. Therefore, we 
must always keep in mind, in using such terms as melancholia, that the 
mental symptoms are not the disease ; we must always consciouslv refer 
those symptoms to the brain convolutions in the diagnosis and treatment 
of mental diseases, which are simply brain disorders of difterent kinds in 
which the mental symptoms predominate. In assigning causes, we may 
say that peripheral irritations, tmannias, and moral and mental shocks 
have caused the disease: but we must clearly keep in mind that rho 



I 



54 STATES OF MENTAL DEPRESSION. 

onental symptoms of the disease are caused by the disordered working of 
the encephalic tissue. If that remains sound in structure and working, 
no amount of anaemia or moral shock will cause any real mental disease. 

States of mental depression are, in some of their forms, of all mental 
diseases those that are nearest mental health. They shade off by imper- 
ceptible* degress into mere physiological conditions of mind and brain. 
To be able to feel ordinary pain implies an encephalic tissue for the pur- 
pose. To be very sensitive to joain implies that the tissue is acutely 
receptive of impressions. So with mental pain there can be no doubt 
that the healthy physiological condition of the encephalic tissue in the 
brain convolutions through which ordinary or mental pain is felt is one 
between extreme callousness to impressions and extreme sensitiveness. 
A man in robust health, well exercised, does not feel pain nearly so 
acutely, and bears it better than when he is weak and run down. Those 
principles apply equally to the feeling and the bearing of mental pain. 
To experience emotion at all — to feel — implies an encephalic structure 
for this purpose. The most casual study of the affective capacity in 
human beings shows us that it differs enormously in different persons. 
One man w^ll lose his children or his fortune, or see the most terrible 
sights, and he will not feel keenly at all, because his brain convolutions 
that subserve feeling are not in their essential nature very receptive and 
sensitive. Another person will be thrown into very great grief, and feel 
acute agony, at the loss of a favorite dog. I had a lady patient once, 
A. A., who would be for days depressed, and suffer mentally, if a friend 
did not receive her as cordially as usual any day. She suffered mental 
torture if a relative spoke sharply to her, and she was absolutely para- 
lyzed in feeling and volition by the death of a sister. She had several 
attacks of mild melancholia produced by most inadequate causes, from 
all of which she recovered quickly and completely. There can be no 
doubt whatever that the finer moulds of brain are mostly very sensitive, 
and the poetic, emotional, and sympathetic natures have always been 
subject to states of painful depression of mind at the critical periods of 
life, and when the physical vigor was below par. Half the poets and 
men of literary genius give ample proof in their writings, 'and in the 
characters they have created or founded on their own experience, that 
they suffered at times intense mental pain. Goethe clearly looked on a 
period of melancholy as one phase in the development of genius. The 
lives and writings of Goethe, Schiller, Carlyle, Cowper, John Stuart 
Mill, Byron, Burns, and George Elliot show that they all had periods in 
their lives when they suffered intense mental pain, and at least one of 
them did actually pass the undefined borderland that separates physio- 
logical mental depression from pathological melancholia. To feel intense 
mental pain is mostly the necessary accompaniment of the capacity to 
feel intense joy. The brain qualities that give intensity to the one give 
also intensity to the other. 

We must take into consideration in. every case not only the sensitive- 
ness and the receptivity, but also the power of bearing pain — the inhibi- 
tory power against pain. Some brains possess great sensitiveness and 
also great power of inhibition. Those are the strong brains, even 
though their temperament and diathesis may handicap them. But when 



STATES OF MENTAL DEPRESSION. 55 

a brain is sensitive, and has little inhibitory power, this combination is a 
source of weakness and of disease. 

There is a morbid constitution and a temperament which predisposes 
to mental pain, but that does not readily feel intense pleasure, and this 
is common enough among common men. It does not imply genius or 
strength in any way, and has no compensating advantages to its pos- 
sessors. Persons with this tendency are of the nervous variety of the 
melancholic temperament, or perhaps, more properly speaking, have the 
melancholic temperament and the nervous diathesis. They are liable to 
lose their sense of wxll-being from slight causes from w^ithin and without 
them. This surplus stock of animal spirits and vis nervosa is soon ex- 
hausted. They want mental balance and resistive power. They are 
very often persons with strong unreasoning likes and dislikes, who are 
swayed by their instincts, and cannot correct and guide those by their 
reasoning power. They are often morbidly introspective and imagina- 
tive, and very often irritable and excitable. Bodily, they do not lay on 
fat at the ages wdien fat is physiological : their digestion is not their 
strong point; when tired, they are sleepless. 

Such a temperament and diathesis are strongly hereditary, and, I 
think, are very apt to be derived in the male sex from the mother, and 
in the female sex from the fiather. It strongly predisposes to attacks of 
melancholia as well as to attacks of mental depression in what may be 
called a physiological form after many bodily diseases. In such persons, 
fevers, lung affections, and cardiac troubles are apt to be accompanied 
and to be followed during convalescence by mental depression. This is 
a serious complication in those circumstances, for it retards recovery, 
and tends towards relapses. It is, no doubt, another expression of that 
lack of trophic and recuperative energy of the brain which we shall see 
is so marked a symptom in melancholia. The great physiological crises 
of life — teething, puberty, adolescence, the climacteric, senility, preg- 
nancy, childbirth, and lactation — are apt to be complicated by attacks 
of the neuroses in such persons : loss of blood, over-w^ork, want of sleep, 
over-anxiety, and menstruation are also commonly accompanied by de- 
pression of spirits. Children of this brain constitution often exhibit a 
kind of child-melancholy at a ver}^ early period. I have known such a 
child at five years of age become intensely depressed, cr}^, and moan for 
hours, because it was afraid of the "hell" which its mother (of the same 
temperament) had described as being the portion of bad boys who tore 
their pinafores, sinned against God, and did not obey their mammas. 
Precocity, over-sensitiveness, unhealthy strictness in morals and religion 
(for a child), a too vivid imagination, want of courage, thinness, and a 
craving for animal food arc characteristic of such children. 

It is most difficult to draw a line of definition between mere. '" lowness 
of spirits," ordinary "depression of mind," popular ''melanclioly" or 
"hypochondria," and the pathological melancholia. They shade of^" into 
each other by fine degrees ; and yet it is most important to make a clear 
distinction. The general public, who are very fond of hearing profes- 
sional gossip in regard to medico-psycliological })robleins. and of retailing 
as gospel the illogical travesties and })opularized versions of such prob- 
lems which some ])rofessional men retail, have an idea tliat tliose who 



56 STATES OF MENTAL DEPKESSION. 

have studied the subject most deeply have come to the conclusion that 
all men are mad; and this because Ave say that no man comes up to an 
ideal standard of mind, and few men but are subject to mental depres- 
sion or excitement, or to lose their self-control at times. Such a popular 
belief does harm, because it is utterly opposed to fact, and tends towards 
confusion and misconception in regard to a physician's most serious 
problems. It is necessary, therefore, to attempt accurate definitions, 
even though they may not cover the whole ground. 

Mere melancholy might be defined as a sense of ill-being, and a feeling 
of mental pain with no real perversion of the normal reasoning power, no 
morbid loss of self-control, no uncontrollable impulses towards suicide, 
the power of working not being destroyed, and the ordinary interests of 
life lessened, not abolished. 

Melancholia might be defined as mental pain, and sense of ill-being, 
more intense than in melancholy, with loss of self-control or insane delu- 
sions, or uncontrollable impulses towards suicide, with no proper capacity 
left to follow ordinary avocations, with some of the ordinary interests of 
life destroyed, and generally with marked bodily symptoms, all these 
things showing a diseased activity of the highest brain centres. 

Typical cases exhibiting these two conditions are totally difierent and 
distinguishable, and the only excuses for confounding them are that they 
shade ofi" into each other, that we have no absolutely definite scientific 
test to distinguish them, that they are both in many cases the outcome 
of the same temperament and diathesis, and that they both have some- 
thing of the same nature, both psychologically and physiologically. A 
typical case of melancholia, as we shall see, runs a somewhat definite 
course like a fever, and has often all the characters of an acute disease, 
in this being to the physician entirely unlike a mere feeling of melancholy. 

Though, in the statistics of asylums, melancholia does not appear to 
be the most frequent of the varieties of mental disease, yet I think that 
if statistics of its real frequency in all its forms, mild and severe, could 
be got, it would be found that it is the most common form. In its milder 
varieties it is a very manageable disease at home, in this contrasting 
strongly with cases of mania. For this reason many cases are treated 
at home and not sent to asylums at all. 

Before seeing cases of any disease, one should know what to look for. 
As a general rule, one has less difiiculty in the examination of a case of 
melancholia than of any other kind of insanity. The whole process of 
ascertaining the symptoms that are present is more like that in any 
bodily disease. The patient is usually conscious that there is something 
wrong with him, which is not the case in most forms of insanity. It is, 
in fact, the sanest kind of insanity. He can describe some of his symp- 
toms. Many of his subjective sensations are reliable, and are very 
valuable in diagnosis and treatment. It is not all a process of deduction 
from speech and conduct and objective signs. The patient will tell you 
in the first place very likely that he is unhappy, and feels mental pain 
and depression. He will then tell you why he feels this, or if he does 
not, you ask him why he is depressed, and then will probably come out 
the first sign of mental unsoundness. In nine cases out of ten, melan- 
cholic patients assign as a cause of their misery what is not its cause at 



STATES OF MENTAL DEPRESSION. 57 

all. Here it is where their insane delusions, their false, ungrounded 
beliefs come in. I have analyzed the "causes" assigned by melancholies 
that I have had under my care during the past seven years for their own 
depression, and I find them to be wrong in ninety per cent, of the cases. 
Melancholia occurs in many forms, with very various psychological 
and clinical symptoms. The following are, I think, the most common 
varieties, and I think the study of the disease will be made easier, and 
its treatment become more intelligible, by considering those varieties 
seriatim, viz. : 

a. Simple melancholia. 

h. Hypochondriacal melancholia. 

e. Delusional melancholia. 

d. Excited (motor) melancholia. 

e. Resistive (obstinate) melancholia. 

/. Epileptiform (convulsive) melancholia. 

g. Organic (coarse brain disease) melancholia. 

Ji. Suicidal and homicidal melancholia. 

Simple Melancholia. — The best way to begin the study of melancholia 
is to take a case of what may be called simple melancholia, that is, one 
that is both very mild and unc6mplicated, and where the affective de- 
pression and pain are far more marked than the intellectual or volitional 
aberrations. • Such cases are very common and most of them are never 
sent to asylums or come under the notice of specialists ; indeed, many of 
them never come under the notice of any doctor at all, for it is charac- 
teristic of many of them that they have a great disinclination to consult 
our profession. Such a case as this is a good example : A. B., a gentle- 
man of 60, of a neurotic but not insane stock, had inherited from his 
mother a neurotic diathesis and a melancholic temperament, and was of 
a sensitive, vivacious, sympathetic disposition, and very studious habits. 
He had kept his brain at full work nearly all his life by his ambition and 
volitional force. The want of adjustment I count as really an imperfec- 
tion of brain constitution ; the inhibitory or volitional power is so great 
as to force the rest of the brain to work or suffer longer than its innate 
trophic or dynamic power would safely allow. In a perfectly ordered 
brain the fatigue of exhausted energizing should be so absolute as to 
compel rest. There should be no power in a higher centre to compel a 
lower centre to do more than it is fitted for. Yet we know that this is 
commonly counted a great power for a man to possess — to be able to 
work, or think, or feel, or wake, or walk, not according to his innate 
capacity for these things, but according to his wish or the imagined 
necessity of the occasion. It is a dangerous power for those of a neurotic 
inheritance. All went on well till A. B. was about 50, w^hen, after a 
big piece of intellectual work, he began to feel that he was always tired, 
he had a jaded feeling, his work, instead of being a pleasure, became a 
conscious toil, indeed, he seemed capable of feeling no joy in life any 
more. It did not quite amount to a sense of ill-being, but tliat evidence 
and crown of the perfect working of every organ, the undofinable but 
very real feeling of conscious well-being had left him. The common 



68 STATES OF MEXTAL DEPKESSIO^^. 

pleasures of life, the society of Lis wife and children and friends, were no 
longer delightful ; indeed, intercourse with his friends by speech or letter 
was distinctly wearisome, and he avoided it. His courage was manifestly 
lessened, and he was irritable with his children, an unusual thing with 
him. It seemed to him as if his wife and children were less consciously 
dear to him, and this alanned him and made him ashamed. He had a 
feeling as if he had done something wrong to cause this — that it was a 
wrong to them in itself, and must be a judgment on him for some sin. 
His favorite authors and poets seemed to have lost much of their charm. 
His religious duties brought little comfort. His appetite was dulled; 
food and drinks did not tempt him, and after a meal he was uncomfort- 
able. His sexual desire was much lessened. Some of his instincts and 
propensities seemed to be altered. His bowels were costive ; his skin 
seemed to be harsher and drier than normal ; he had not the same feeling 
of reaction after cold bathing ; he could not sleep soundly all the night 
through, and awoke unrefreshed ; he was losing weight a little. 

But all this time he was not very thin or weak, and he could appear 
in public or to his friends just as usual. He had the power to conceal 
all his symptoms from those to whom he did not want them known. 
There were certain curious features, too, in his case. He was always 
worse in the morning — most jDcrsons with any sort of mental pain are — 
but if he would set himself to w^rite a letter, or took a brisk short walk 
in the sunshine, or took a cup of hot coffee, he would feel better and 
happier. In the evenings, too, he would often, in bright* light, after a 
good dinner with a glass or two of wine, and in the society of fr-iends, be 
quite himself again, and feel almost gay for a time. He stopped work, 
travelled and rested, and was well in three months. Since then he has 
had several such attacks, some of them more severe, during which the 
mental pain was more positive and intense, the conscious mental prostra- 
tion greater, and the paralysis of volitional energy more complete, so that 
at times he could not possibly see his friends or put on before them any 
appearance of cheerfulness. At those times the beginnings of delusions 
showed themselves. He believed, and could not correct the false belief 
by reasoning, that he was lost and his prospects ruined, and that his life 
had been wasted and a failure, and that he had not done his duty by his 
profession, or his wife, or his children. At those times, too, his in- 
tellectual processes would be slow and torpid, his power of attention 
Aveakened, and the arrival at any conclusion impossible to him from any 
data whatever. When he consulted me in o*ie of those attacks I recom- 
mended absolute rest, a sea voyage, almost no company, plenty of easily 
digested but fattening diet, some good claret, and animal food only once 
a day. I told him he might live on bread, butter, milk, eggs, fish, and 
fresh vegetables if they agreed with him and he felt that they digested 
well. A tonic and aid to digestion, in the shape of quinine and nitro- 
muriatic acid, was all the medicine I gave him. I did not think he 
needed stimulating nerve tonics, and warned him against opium, which 
some one had recommended, as against his worst enem3^ I told him to 
live out in the fresh air as being nature's great sleep producer, appetizer, 
and tonic. I counselled him against any expenditure of nerve energy 
whatsoever, either in seeing compan3% travelling too fast, walking or 



I 



STATES OF MENTAL DEPEESSION. 59 

talking, in short, he was to take mental, affective, motor, and sexual rest. 
I warned his friends against the common delusion that a man in that 
state needed to be "cheered up" specially. My experience has been 
that such cheering up is a natural process that will come of itself when 
the brain attains its normal trophic and energizing power. I have seen 
many patients still further exhausted by the violent and continuous efforts 
made to cheer them up. 

I gave my opinion as to the prognosis that he would probably get over 
each attack as they came on him, but that he should be extraordinarily 
careful when he came towards old age, and said he would probably be an 
old man before his time. 

As to prophylaxis, I recommended him, when he got better, to do his 
work with great system and order, cutting up his day, like the face of a 
chess-board, into regular divisions, and filling in each with regular work, 
or recreation, or rest. I told him to weigh himself every month, and 
whenever he found he had lost three pounds to stop work and take a 
change or a sea voyage. I recommended the bromide of potassium for 
sleeplessness, in twenty-five grain doses, if fresh air would not do.^ ^ 

That is the type of a very mild case of simple melancholia, caused by 
over brain- work in a person predisposed to it by heredity. In such a 
case it seems as if brain anaemia was present, the morning exacerbation 
after the physiological sleep an'semia pointing to this, relief being ob- 
tained by anything that determined more blood to the organ. 

As an example of simple melancholia with partial paralysis of volition, 
and of that particular kind of morbidness which consists in never 
"making up one's mind," along with. a subtle kind of morbid introspec- 
tion and morbid magnification of small things, the following graphic 
case of A. C. is of much interest: She was a young lady who had 
worked far too hard at school, and so had, I have no doubt, produced 
chronic hyperaemia of her brain membranes, and impaired nutrition of 
her convolutions. I quote from her own description of her mental state. 

"I watch every action, word, and thought, constantly questioning 
them, accounting for them, excusing them, or deprecating them. Every 
day I rise I wish to be happy like the others. I will not torture my 
brain. It is a sin to steal my own happiness and that of others. I 
reason, resolve, and hope ; but the greater the effort to be free the greater 
the struggle. I have been so oppressed Avith this unspeakable distress 
that I feel as if I were two persons — the one tyrannically demanding to 
be gratified, the other protesting and pleading. I am often in despair, 
and feel my life a burden. At night I am glad the day is done; in the 
morning I am in terror the day Avill be a repetition of the former. The 
most trivial incident will occupy my mind ; I discuss it in all its bearings, 
telling myself all the time it is not worthy of my consideration. Some 
one speaks to me, or some one is talking. If the former, I answer (often 
very abstractedly) with the feeling that there is something in my mind; 
then I return to the triviality. If I have forgotten it I must remember 
it, and then witli a distinct eflfbrt put it away from my mind. It steals 
back. I tell myself that I liave already discussed it, but I must repeat 
the whole matter to myself, and that witli no ordinary process of thought. 
I seem to feel a strange strain on my memory, and again I have to use 



60 STATES OF MENTAL DEPKESSION. 

an effort to banish this nothing. Again it will arise and be dismissed; 
and I number the times as carefully as if much depended on it. The 
efforts to dismiss the subject cause the blood to rush to my head, the 
perspiration to break, and I often find my hands clenched in the struggle. 
All through this I can bear a calm exterior, no one knowing how I am 
tortured. This fret goes on in every circumstance. I try to divert 
myself, and go here and there, seek the conversation of some one, seek 
solitude, try the piano, then a book, until I feel like a haunted creature. 
This strain upon my mind I cannot endure. I seem paralyzed. I can- 
not perform anything I wish to do, though I spend any amount of energy 
in fretting. 

"To one whose mind is healthy thoughts come and go unnoticed, with 
me they have to be faced, thought about in a peculiar fashion, and then 
disposed of as finished, and this often when I am utterly wearied and would 
be at peace; but the call is imperative. This goes on to the hindrance 
of all natural action. If I were told the staircase was on fire and I had 
only a minute to escape, and the thought arose — 'Have they sent for 
fire engines ? It is probable the man who has the key is at hand. Is 
the man a careful sort of person ? Will the key be hanging on a peg ? 
Am I thinking rightly? Perhaps they don't lock the depot.' My foot 
would be lifted to go down. I should be conscious to excitement that I 
was losing my chance — but I should be unable to stir, until all these 
absurdities were entertained and disposed of. In the most critical 
moments of my life, when I ought to have been so engrossed as to leave 
no room for any secondary thoughts, I have been oppressed by the 
inability to be at peace. And in 'the most ordinary circumstances it is 
all the same. Let me instance the other morning I went to walk. The 
day was biting cold, but I was unable to proceed except by jerks. Once 
I got arrested — my feet in a muddy pool. One foot was lifted to go, 
knowing that it was not good to be standing in water, but there I was 
fast, the cause of detention being the discussing w^ith myself the reasons 
why I should not stand in that pool." 

The morbid "watching of herself," as she calls it, is a very common 
psychological phenomenon. The morbid doubting, too, and inability to 
make up her mind to action, are also common. I know a young man of 
a most neurotic family, whose sister, C. E., was insane and suffered from 
the variety of mania that I shall describe, who suffered from simple 
melancholia, but still more from this "insanity of doubt," for he would 
stop half an hour in dressing to decide w^hich stocking to put on first, 
and has been known to stand for two hours w^here three roads met, trying 
to decide which to take. If hurried or forced during those morbid 
periods of doubt, he suffers intense mental pain, and is inclined to resist 
dictation. Such cases throw much light on many of the resistive and 
apparently "obstinate" moods of the insane, who are too much affected 
intellectually to describe their subjective sensations, or to give their 
reasons for their conduct. 

To return to A. C, w^hose letter I have quoted. She could not walk 
far, had palpitation when she ran, had no courage to ride, had much 
confusion and pain at vertex of head after reading or thinking hard. 



STATES OF MENTAL DEPKESSION. 61 

She was fairly nourished, slept well, menstruation was regular, and she 
looked a sweet, bright, intelligent girl. 

During adolescence she had suffered much from neuralgia, severe 
headaches, depression of spirits, and a few attacks of hysteria, and had 
no surplus stock of nerve energy or trophic power. She had used up in 
school-work the energy that ought to have gone to build up her brain 
and body, and had thus caused the brain hyperaemia which I believed to 
be present. I prescribed life in the open air, no reading, no work 
amongst the poor (that had strained her by over-sympathy with them), to 
live largely on non-stimulating fattening food, to take bromide and iodide 
of potassium and strychnine meantime till she could get to Schwalbach 
and take the baths and chalybeate waters there. This she did, and im- 
proved greatly, and she writes me lately: ''I have learned to have many 
open air interests. I have during this severe winter enjoyed myself in 
almost boyish enjoyments, contrary to my natural bent. I am an indus- 
trious gardener, and an enthusiast in poultry keeping. I am fond of 
drawing and painting. I now busy myself in feminine pursuits, and have 
a most pleasant life; but all this is sometimes spoiled still by the former 
misery which renders all the occupations an effort. But I never give in ; 
and one looking on would never guess that anything ailed me." 

I have on several occasions met with cases of this type in women of a' 
nervous diathesis or heredity, bo'th before and after marriage, in which 
the morbid doubting and introspection were very prominent features. 

I have met with many cases very similar to this, but each one with its 
own individual features. It seems to me no diseases are so individual- 
ized in each case as mental diseases. It seems as if the brain showed its 
infinite dominance over every other organ by the extraordinary variety 
in its derangements. One gentleman, A. D., set. 50, I used to attend, 
had all the features of the one I have described, with the addition of a 
distinct delusion, viz., that syphilis which he had had in youth had been 
transmitted to his children. There they were before him, as plump and 
healthy, and rosy as they could be, and yet he would say they looked 
like death and disease, and would remorsefully point to almost invisible 
pimples or skin marks, and affirm they were evidence of his belief. He 
could not be got to go to business, though quite capable of doing it other- 
wise, and lost his appointment thereby. Nothing would induce him to 
walk out alone. In his case his bodily health was really very good. 
He has never quite recovered from his second attack in which I saw him. 

Such attacks of simple melancholia sometimes occur in young persons 
at puberty or adolescence. In such cases there is always a strong heredi- 
tary tendency towards the neuroses if not to mental disease. I was 
asked to see A. E., a girl of 15, some of whose mother's family had been 
insane, who was clever and studious, though at one time wild and mis- 
managed, who, after hearing a sermon one Sunday, became very de- 
pressed, insisted on praying with the other girls in the school, and wa« a 
little excited and demonstrative. The great feature of her case was one 
which, in different forms, is very connnon in young brains that are sub- 
ject to the psychoses, viz., a sort of automatic, rliytlimical, and emo- 
tional movement. She became what slie and tliose about her called 
"agonized" when left alone, that is, slie would irot into a state of do- 



62 STATES OF MENTAL DEPRESSION. 

pressed brain action ; kneeling, uttering over and over again rhythmical 
expressions of prayer, swaying her body backwards and forwards, and 
wringing her hands at intervals. When with others, or at her lessons, 
she would appear to be quite well, but reserved and shy, and could not 
learn her lessons so well as before, and had no tendency to romp. She 
was becoming paler and thinner. She ate well. She had never men- 
struated. Her intelligence, when I saw her, w^as normal ; and she said 
she was quite well, and would admit no depression. She said she had 
headache in one temple, and felt her back weak. She admitted, on being 
pressed, that several things troubled her, but that they were not of much 
consequence, and that she was "nervous" and could not control herself 
at times. She said she could not take much interest in her lessons, or 
play, or anything else. I sent her at once to the country, to ride, walk, 
live in the open air, to take aloes, iron, and quinine, to read little, not 
to go to church for a short time, to give up coffee and tea, and animal 
food, but take milk and eggs ad libitum. At first, for a month or two, 
she used to feel depressed, slightly agitated before people, but then soon 
got girlish, romping, and quite well. After a tour in Switzerland she 
was fat, cheerful, and vigorous, with no undue religious emotionalism. 
She menstruated soon. If one had the guidance of such a life, much, I 
think, might be done by prophylaxis to ward off attacks of the neuroses. 
But one great contingency it is most diflScult to know how to meet, viz., 
marriage. If such a woman marries, she runs innumerable risks in 
pregnancy, childbirth, and lactation ; and she may have weakly children ; 
if she remains single, she runs nearly as many in unused functions, hys- 
teria, unsatisfied cravings, objectless emotion, and want of natural in- 
terests in life. For herself she would get more happiness in life by mar- 
rying ; for the world it is better that she should not. But prophylaxis 
in mode of living, attention to keep the body nutrition at all times up to 
the highest mark, and early treatment of the beginnings of the evil 
would, I am sure, greatly ward ofi" the risks of another attack. I need 
hardly say that the " cause " assigned — viz., the sermon she heard — had 
in reality less to do with the disease than the brain she took to church, 
predisposed by heredity, exhausted by study, and the unnatural life at a 
boarding-school, starved of fresh air, and rendered unstable by the physi- 
ological crisis of commencing menstruation. And here I would say, 
once for all, about unusual religious services, exciting preaching, and 
"revival meetings," that, as a physician, I have no objection to them at 
all, rather the contrary, but I think they are only suited to stolid healthy 
brains, and should on no account be attended by persons with weak 
heads, excitable dispositions, and neurotic constitutions. 

The imm^ense variety that the combination of different mental or ner- 
vous symptoms is capable of producing, comes out in this the simplest of 
all mental ailments. In some cases the mental pain is, as it were, nega- 
tive rather than positive, in others there is a simple blunting of the emo- 
tions with a tinge of depression ; in others, again, the normal gayety dis- 
appears, in others there is a paralysis of energy, in others a sudden 
ceasing to care anything about the usual interests of life, in others a 
natural suspiciousness of temperament becomes morbid and causes mental 
pain, in others a natural diffidence of disposition increases so as to be- 



STATES OF MENTAL DEPRESSION. 63 

come a disease and to cause intense unhappiness, and in others it is a 
mere tedium vitce. It would swell the bulk of this lecture to utterly im- 
possible proportions were I to give cases illustrative of all these condi- 
tions, but, to show the ordinary types, I give one or two. I was once 
consulted about a lady, A. F., about 40 years of age; who was said to 
have had a similar attack some years before and to have recovered. She 
had given up her business, and had, therefore, no setious interests in life. 
She had been for some months ill. When well, she had been a clever 
active w^oman in body and mind, had conducted a business enthusiasti- 
cally and profitably, was sociable and a favorite with her friends. When 
I saw her she had little mental pain, but she had no mental or bodily 
pleasure. She had no energy — no interest in anything. She had no 
delusion, except an unreasoning belief that she could not get better could 
be considered one. She was utterly careless about her dress, or appear- 
ance, or cleanliness. She was obstinate about some things ; she cared 
for nothing or nobody. The only thing in which she took any interest 
was talking about her symptoms. Her memory was good, her reasoning 
power was good. She was thin and flabby. She would do nothing she 
was told. She recovered after about three years. 

I have seen many cases where the mental symptom of depression was 
so subsidiary to general nervous prostration, incapacity to Avalk, work, to 
digest food, or to fatten, and so ^Vas overlooked. I knew one case, A. 
G., where, as the result of many causes of nervous exhaustion, along 
with mild mental depression, indigestion, and the most distressing weak- 
ness, the cardiac innervation was so weak that the recumbent position 
had to be kept almost constantly for a time for fear of syncope. She 
recovered in two years under tonics, changes of scene, and a warm 
climate. Many of these cases are of the same essential nature as typical 
mild melancholia. American medical authors have much to say about 
nervous exhaustion and prostration — the Neurasthenia of Beard. For 
the cure of some of the cases a plan of treatment has been adopted, the 
most irrational that was ever conceived by the medical mind. It is that 
of the massage^ or making the muscles contract and the blood circulate 
faster by rapid percussion, squeezing and rubbing the body all over every 
day, while the patient is confined to bed, instead of walking in the fresh 
air. Such a plan may suit a few exceptional cases with weak hearts, 
but to apply it to many cases seems to me utterly absurd. It seems as 
if the air and climate, and the mode of life and education in some parts 
of America were so stimulating, that the brain there sometimes exhausted 
both its own trophic and energizing power, and paid the penalty by pro- 
longed periods of " Neurasthenia." The natural cure w^ould seem change 
to a more sleepy climate. 

There are some instances where the higher affective life is paralyzed, 
while the lower appetites and propensities arc left intact, if not actually 
increased. A melancholic patient once said to me, " I canna think, 
canna do anything, canna care for anything — wife or children, or any- 
thing at all, but meat, meat ! If they were all lying dead I would not 
care a curse if I got meat." 

In certain other cases there are extraordinary combinations of mental 



64 STATES OF MENTAL DEPRESSION. 

symptoms along with the mental depression, of which this is an example, 
with a morbid fear of forgetting names and words : 

A. H., set. 64. Disposition cheerful. Temperament sanguine, but 
not a "nervous" man at all. Habits most industrious, steady, and ac- 
curate, but somewhat sedentary. A clever and intelligent business man. 
Mother died of some brain affection, without distinct mental disease. 
The only other predisposing cause Avas his time of life — the climacteric. 
The exciting cause of the aggravation of the mental state which neces- 
sitated his coming to this asylum was the death of a sister. His present 
attack has been of gradual onset, beginning in a very mild way some 
years back, getting worse, and only assuming a form that could be 
reckoned technical insanity four months ago. He began by being fan- 
ciful and disinclined for bodily or mental exertion ; in fact, a kind of 
morbid laziness came over him. Laziness is more often a real disease 
than is commonly imagined ; it simply means, in those cases, diminished 
evolution of nerve energy. He gradually and steadily got worse, falling- 
more under the influence of his morbid fancies. They produced insane 
conduct five months ago, w^hich showed itself as morbid restlessness, 
shouting, and acting on his unfounded suspicions. He suspected that 
people were plotting against him, that there was a society in the next 
street, the members of which got into his room at night and stole his 
clothes and watch. He got into silly conservative habits, so that the 
slightest new way of the house was most disagreeable to him. He could 
not be got to go out and walk, or to attempt business. Once he threatened 
to commit suicide with a razor, but seemed to have no serious intention 
to hurt himself. His memory became impaired in regard to some things, 
and he thought it worse than it really was. His affection for his rela- 
tions diminished, and he lost his social instincts. 

On his admission into the asylum he was mildly depressed. His 
morbid suspicions seemed not only to be a symptom of the disease, but 
also a cause of depression. He was restless, fidgety, easily startled, and 
perversely irritable. There was some limited enfeeblement of mind in 
regard to certain things, e. g., inability to identify familiar persons and 
places, or to recall events at will, he had groundless fears, and his manner 
was hesitating. His memory, in regard to most matters, was unimpaired, 
but in regard to names it was most peculiar, for he had a feeling, almost 
amounting to terror, that he would forget some familiar name. His voli- 
tion was quite weak as regards its positive action, but there was a good 
deal of obstinacy. In appearance he was fairly nourished, but flabby 
and slightly paretic looking. His left shoulder fell a little. His left 
side seemed a little weaker, but about this there was a doubt, and his 
articulation was rather indistinct. He said he had a difficulty of swallow- 
ing. His tongue seemed to go slightly to the right side Avhen put out. 
Sensory power was somewhat dulled, and reflexes were normal. His 
tongue was dry and bare in the centre. Pulse 72, and weak. Tem- 
perature 96.8°, being generally under this in the morning, though in the 
evening it was sometimes 97°, the average evening temperature being 
96.6°. This low temperature was evidently a part of his disease. He 
w^as put on strychnine and iron, nourishing diet, and as much fresh air 
as he could take, while every effort Avas made to amuse and occupy him. 



STATES OF MENTAL DEPRESSION. 65 

He improved in pith and strength, but the apparent slight hemi-paresis 
often passed to the right side. Mentally he improved, too, by being 
kept in a steady routine of physiological living. Anything out of this 
routine annoyed him exceedingly, and put him much about. After a 
time his mental depression centred round his fear of not " remembering 
names." In reality, he would remember them pretty well, but he would , 
get most unhappy, and sometimes excited, and most irritable through the 
morbid fear he would forget them. In reading the newspaper, he would 
mark certain names down on paper lest he should forget them. He 
would come up to me and ask in the most earnest tone, as if his life de- 
pended on the answer — " Doctor, can you tell me the name of that burn 
in Fife I fished in in 1850 ? I can't get it, and it makes me miserable." 
At times it seemed as if he had a dreamy mental vision of great rows of 
long botanical and topographical names, whose exact spelling and pro- 
nunciation he could not make out, and that this made him utterly miser- 
able. He got very stout after about six months, and went (much against 
his will) to the asylum seaside house, where he still further improved, 
and then unwillingly went home, where he lives a mentally depressed, 
peculiar life, fearing the loss of words and names still. If his newspaper 
does not come at the proper moment, or if a relative sits down on an 
unusual chair, he is very miserable. The things that he fears, and that 
put him about, are trivial unaccustomed things, and the greater things 
of his life do not afiect him at all. A keen, sharp, business man, he 
cares nothing now for money or business. He shows a mild dementia, 
along with a mild melancholia. Every effort is made to keep up his 
bodily health and stoutness by good food, fresh air, and nerve tonics, and 
though he will never recover, he enjoys some happiness. He can origi- 
nate nothing, and new events annoy him. Any attempt to argue with 
him, or try and convince him of the absurdity of his whims, always 
makes him worse, for his reasoning power is greatly paralyzed. One 
might as reasonably try and convince a man with locomotor ataxia that 
he should not lift his leg so high and should put it down more steadily. 
His brain is clearly anemic, and partly atrophied, and energizes feebly. 
The things that in an ordinary man would cause just a moment's annoy- 
ance, are to him very great things, from his weakness of reasoning power, 
paralysis of volition, and emotional hyper?esthesia. Many of his peculi- 
arities result from his old methodical habits remaining in an insane and 
grotesque form. He has been three years ill, and the slightly paralytic 
symptoms are proof to me that he has some brain degeneration, probably 
combined with a good deal of convolutional atrophy. 

In the cases I have referred to, the condition of simple melancholia 
has been the mental disease from beginning to end, but very often it is 
merely a stage in the clinical history, and the case soon assumes a deeper 
and different form of depression, or in some cases it passes into mania. 
It must be clearly understood that the kinds of melancholia I am describ- 
ing are mere varieties, and have not the characters of real diseases or 
pathological entiti<is. I am taking this symptom of depression of mind 
and describing it as melancholia ; and I am taking this depression in 
certain degrees and witli certain marked cliaracters or accompaniments 
in different patients, and describing such cases as I would the varieties 



66 STATES OF MENTAL DEPRESSION. 

of a species of plant, for convenience and clearness. A case may exhibit 
one form of depression of mind at one time and another at another. 

Simple melancholia sometimes becomes chronic, of which this was an 
example, having depression, but great self-control before strangers, intel- 
lectual vigor, morbid sensitiveness as to people knowing about her illness, 
want of real enjoyment of food, but eating plenty, grimacing and swear- 
ing in secret ; almost tearless weeping, wringing her hands, and nervous 
jerkings : 

A. J., aet. 63. No children. Temperament melancholic, and diathesis 
nervous, but disposition lively, happy, and very energetic ; very intelli- 
gent. Habits active ; well educated and well bred. Eor four years she 
had been depressed, unsocial, morbidly shy, and in great dread lest her 
friends should know there was anything wrong. Cannot make up her 
mind about anything, and to any new proposal whatever is always averse; 
changed in ways; not so particular as to dress and cleanliness as in 
health (this is very common in similar cases), and more penurious (also 
common). AVhen she sees strangers or friends she can talk and behave 
very well, and seems almost to enjoy it. Always objects to going any- 
where, but does not like to be left at home. Has no power of coming to 
any resolution, but much of passive resistance and objection. Conceives 
very strong dislikes, reads all day and very quickly, but will not sew, or 
knit, or play ; very acute and observant ; very sure she will never get 
well. As she sits and talks to one, she never looks one in the face, and 
fidgets and jerks, and sometimes makes faces. When alone she swears 
and uses most abominable language, this being of course utterly foreign 
to her real nature and former habits. She says she cannot help it, and 
deplores it — a common symptom in such cases. She says she never 
sleeps, but this is not true, though she sleeps badly at times and walks 
about the room. I have another case, just like this, who "longs for 
sleep," and feels drowsy and sleepy often, but cannot sleep well at night, 
though she takes a nap for an hour every day after dinner. A. J. looks 
fairly well, but is worn looking, and though muscular has fallen off in 
weight and fatness. She had an eczematous skin irritation. Bowels 
costive, tongue furred. 

For treatment, I put this lady on very many things. Opium did 
harm, and so did the vegetable narcotics, all but cannabis Indica in fif- 
teen drop doses, which I gave with good result when she was unusually 
restless and sleepless, combined with thirty grains of the bromide of potas- 
sium. I gave her in succession arsenic, strychnine, iron, quinine, the 
mineral acids, the hypophosphites, salt baths, fresh air, and walking ad 
libitum, cod-liver oil, maltine, employment, milk, fruit, fresh vegetables, 
and farinaceous and fish diet, largely ringing the changes on the tonic 
medicines, with Friedrichshall water every other morning for the bowels. 
The course of arsenic did much good, being followed by an increase of 
body weight. Though she did not get well, yet undoubtedly she got 
fatter and happier and more comfortable to do with, and remains so now 
at the end of three years. It is a mistake to suppose that such cases do 
not need tonic treatment, or that it does no good. Every pound of body 
weight gained means a gain in nervous and mental tone. I recommended 



STATES OF MENTAL DEPKESSION. 67 

quiet places among friends and not much travelling about, which tended 
to excite her. I was always in the fear of her passing into mild exalta- 
tion, and becoming a case of folie circulaire. I have seen strychnine, 
pushed too far in such a case, decidedly tend towards excitement. This 
lady, I need scarcely say, had sought (or her friends had sought for her) 
the advice of many physicians. I have seen such a case get quite w^ell, 
the mental pain passing quite away after six years. This case leads 
naturally to the next variety of melancholia, the hypochondriacal, having 
many of its characters. 

Simple melancholia is in most cases curable ; it does not commonly 
require treatment in an asylum, when the means of the patient admit of 
suitable attendance, change, and treatment elsewhere ; it never kills 
directly by exhaustion, and seldom ends in dementia. The exceptions to 
its curability occur in the very advanced periods of life when the brain 
is retrogressing or degenerating, or where it occurs as an accompaniment 
of organic brain disease, and this is not uncommon when there is a strong 
neurotic heredity as well as such disease. 

Simple depression frequently precedes other forms of mental disease 
than melancholia, some authorities going the length of saying that it is 
the necessary prelude to all kinds of insanity whatever. My experience 
is that it is not the necessary prelude to mania or to general paralysis, 
but that it is a very frequent one indeed. 

Hypochondkiacal Melancholia. — The next variety of melancholia 
is a rather well-marked one. In seriousness it exceeds the simple form. 
It is further away from mental health, psychologically and bodily. The 
symptoms are more decided and positive. Along with the affective de- 
rangement there is more judging aberration, and less inhibition over 
morbid speech and conduct, whilst the radical instincts and habits of life 
are not affected, nor is the self-control so lost, as they are in the severer 
varieties of the disease. The mental pain has a certain superficialness 
and want of intensity, and the cause of it is always stated by the patient 
to be diseases or disorder of the bodily organs that are not real, or, if 
real, are exaggerated out of all proportion to their real severity in the 
patient's mind. As simple melancholia has a sane initial period, and 
many cases are never legally or technically insane at all, so hypochon- 
driacal melancholia has generally a sane stage and a sane twin brother 
called hypochondriasis, which is usually so lightly though c of, and so 
misunderstood, as to be for the most part thought a subject of laughter 
to the patient's friends, and is always popularly talked of as being a state 
that the patient has got into through his own fiult, and could get out of 
by the exercise of his own volition. In hypochondriacal melancholia a 
sense of ill-being is substituted for the healthy pleasure of living, but the 
ill-being is localized in some organ or function of tlie body. The pa- 
tient's depressed feelings all centre round himself, his health, or the per- 
formance of his bodily or mental functions. He is all out of sorts, he 
cannot digest his food, his bowels will never act, his kidneys or liver are 
wrong, he has no stomach, his heart is weak, and he asks you to feel his 
pulse, which is just going to stop beating, lie is paralyzed, and will not 
move a limb till he forgets his fancy for a. moment ; he cannot tliink 
because his brain is made of lead ; he is made of irlass, and will break if 



68 STATES OF MENTAL DEPKESSION. 

roughly handled. There are no limits to the fancies of the hypochon- 
driac or the hypochondriacal melancholic. The way we distinguish them 
— the sane from the insane hypochondriac — is this : a man may have 
any conceivably absurd fancy about himself, but if he can do his work in 
the world, and does no harm to himself, and has a fair amount of self- 
control ; if he can pick himself wp mentally and in conduct at will, and 
has the power to stop talking of his fancies when he wishes, even though 
he revels in the descriptions of his own evacuations, consults all the doc- 
tors he can afford to pay or who will give him advice without pay, and 
swallows all the physic he can afford to buy, we call him merely a hypo- 
chondriac ; but if he has real and intense mental depression that he can- 
not throw off, if he loses his self-control, outrages decency openly, prac- 
tises things that will soon end his days, or threatens to take away his 
own life, and cannot at will withdraw his mind and speech from his delu- 
sion, then we call him a melancholic of the hypochondriacal type, and, 
if necessary, put him under restraint. But, as you see, there is no line 
of demarcation. The one condition is often the first stage of the other. 
From a physiological point of view the afferent impressions from the 
organ implicated in the delusion sent up to the brain are unpleasant, 
instead of, as they should be, pleasant. The secondary cause may be 
real peripheral disorder. A man's liver may not be working well, and 
causing him uneasiness, or his stomach may not be doing its work well, 
or his bowels may be costive (they usually are), or he may have actual 
disease in the part that he says is wrong, but none of these things would 
cause the mental phenomena of hypochondria if the man's brain convo- 
lutions were working healthily, therefore the real cause must be referred 
to the brain. 

The following was a case of hypochondriacal melancholia of short 
duration : 

A. K., aet. 67, unmarried. Disposition eccentric, suspicious, obstinate, 
and unsocial. Habits sober, but not continuously industrious. Has had 
three previous attacks, all of melancholia of a hypochondriacal character, 
treated in an asylum. No ascertained heredity towards the neuroses. 
It was said that he had a fall on his head when he was ten years old, 
and had never been right since, but I attached no importance to this 
story. The exciting cause of his attack was said to be masturbation, but 
whether this was a cause or a symptom I could not clearly make out. 
He was said to have become depressed three months ago, to have had 
suicidal feelings, to which he gave loud expression, to have lost his self- 
confidence ; and he became perfectly helpless and sleepless, according to 
his own account. He has eaten voraciously all the time, and has not 
fallen off in looks or weight. He came to the Asylum voluntarily, and 
considered his case was so urgent that he sent for me out of church. He 
said he felt nervous and depressed, and was afraid every minute that he 
would lose his self-control. He was full of fancies as to the bad state of 
his own bodily health — that his boAvels were very costive, and that he 
had no appetite whatever. He wanted to be most carefully examined as 
to the state of his lungs and heart, and more especially as to his sexual 
organs. He had a real chronic enlargement of one of his testicles, and 
insisted that he had a sore on his penis, the existence of which required 



STATES OF MENTAL DEPEESSION. 69 

a magnifying glass to determine. His temperature, pulse, and all his 
organs . were normal ; he was well nourished. He insisted he had a 
serious skin eruption, which was really a little acne on his back. He 
was obtrusively suicidal in his expressions, though it ought to have been 
clear to him that if he was prevented from putting an end to his life he 
would soon die of some one of the numerous diseases he had. He re- 
mained in this state for about two months and a half, and was subjected 
to rather a calm but strict discipline at first. He was most acute about 
money matters, most fault-finding as to his food, and said he did not 
sleep, when in reality he snored all night. He was inclined to be dis- 
contented because he did not receive that amount of attention which his 
case deserved. I never laughed at him, or pooh-poohed him, nor courted 
his conversation, but put him on tonics, and made him live in the fresh 
air, and occupy himself pretty constantly. He improved, and was pretty 
nearly recovered in three months from his admission, in another six 
months being quite lively and wanting to get married. 

Here is another case of a deeper and more serious nature, and of a 
longer duration, of the same type, the cause being disappointment, the 
sensations, appetites, and propensities being changed ; travel aggravating 
the symptoms, which were very demonstrative, w^ith suicidal talk and 
ludicrous attempts ; strychnine, discipline, and fresh air having a very 
good eifect, with a great gain in weight in six months : 

A. L., aet. 38. Temperament melancholic. Disposition quiet, 
thoughtful, gloomy, energetic, enthusiastic. Habits temperate ; and 
very hard working. Eond of active work rather than study. Had had 
a previous attack, lasting three months, of the same character as that 
about to be described, but not so severe, and treated at home. Maternal 
uncle and aunt eccentric, if not insane. The existing cause of the present 
attack was a disappointment. Jt began by simple depression and in- 
capacity for professional work. The bodily symptoms were at first sleep- 
lessness, and then a curious feeling in his head as if it was made of lead. 
His thoughts became more and more concentrated on his health and the 
state of his organs. His appetites and propensities changed. Instead 
of being very fond of animal food, he could not eat it at all. Instead of 
having the nisus generativus keenly, and indulging it freely, his sexual 
appetite was gone. He had had non-specific psoriasis when well, and it 
had disappeared (this I have noticed in insane patients very often). He 
had tried the usual plan of travel and change of scene, but he had been 
the worse for it, as often occurs in melancholia. There is scarcely a 
point on which I have so much difiiculty in the early treatment of melan- 
cholia as whether to send away patients to travel or not ; and if they are 
to go from home, where to send them to. Quick travelling, and going 
to many places in a short time, is nearly always bad for a patient. Big 
noisy hotels and an exciting life are also nearly always bad ; but then 
one must have change of some sort, breaking oft' old associations, and 
different air, and scenery, and employment. The fiict is, that no definite 
rules can be laid down on this subject ; but there are a few considerations 
that help to guide one. In the very early stages of the disease, wlien 
the mental pain is merely incipient, travel abroad often does good, if it is 
done in a wsystematic, methodical leisurely Avay. If the disease has ad- 



70 STATES OF MENTAL DEPRESSION. 

vanced so far that the power of attention is much impaired, then a quiet 
country place, where there are few visitors, is best. If the bodily con- 
dition is very weak and exhausted, travelling often does more harm than 
good. If there are delusions of suspicion very strong, so that the 
patient is always imagining that people are looking at him, speaking 
about him, following him, then the quieter he is kept the better. 

On admission, A. L. was much depressed, and very demonstrative in 
his account of his feelings and ailments. He could not read, he said, or 
understand what he read. He took the gloomiest view of himself and 
all his concerns ; was very suspicious, thinking that people were watching 
him ; imagining he was paralyzed in sensation, and partly in motion ; 
that he had no appetite, though he ate voraciously, and, when caught in 
the act, saying that his appetite was an unreal, unnatural one. He said 
his face and features were quite changed, and he wailfiilly contrasted 
his present looks with his former appearance. He went and made faces 
at the looking-glass, and said he could not help it. Said his natural 
affection for his wdfe and children was gone, and his senses of taste and 
smell were dulled, but there w^as no evidence of it. He said his brain 
felt as if "made of lead," and had a "contracted" feeling. He was 
well nourished and muscular, and all his organs were sound but his 
digestive system, which was clearly out of order. His tongue was furred 
and flabby, taking the marks of the teeth ; his bowels were costive ; his 
pulse was 68, and good; his morning temperature was 97°, and the 
evening 96.8°. He was put on strychnine in one-thirty-second grain 
doses and quinine, and he affirmed that the strychnine did him good; 
that he felt consciously the better for it; that it pulled him up, and 
enabled him to exercise more inhibition over his actions, and he cer- 
tainly could tell when it was omitted from the mixture. He was sent to 
walk all about into town and into the country, and though he often re- 
ferred to suicide, it was assumed in his case that there was no real 
danger. One day he returned from a walk alone in a most excited state. 
He said he had attempted suicide, and disgraced himself for life. What 
was he to do ? It appeared he had come upon a flag-staff, and had 
taken one end of the rope, and tied it around his neck, and had then 
taken the other in his hand, and attempted to hoist himself up the staff I 
But there was no mark. Another day he lay down in a ditch with a 
little mud at the bottom, and said he had tried to drown himself, coming 
home with his clothes all wet. In fact, there was always an element of the 
ludicrous in his misery and in his mode of expressing it. Regarding the 
suicidal efforts and expressions of hypochondriacal melancholies, though 
there is little real risk, yet there is some. A doctor patient of mine 
once took a poisonous dose of morphia (doctors always poison themselves 
when they want to commit suicide, just as soldiers ahvays shoot them- 
selves), and nearly died. When A. L.'s mind could be distracted, and 
he could be got to talk of anything but his own bad feelings, he was 
rational, intelligent, and his memory good, this, too, being characteristic 
of such patients. He got various tonics along with the strychnine — 
viz., iron, arsenic, vegetable bitters, the phosphates — but my own impres- 
sion is that the strychnine did the most good. 

In three and a half months he was so far improved that he believed 



STATES OF MENTAL DEPRESSION. 71 

he was to get well ultimately, and this in a melancholy case is one of the 
first and one of the surest signs of commencing recovery. He gained a 
stone in weight. He could divert his attention more easily from him- 
self. His mental pain was less, his irritability greater, and his head 
felt better. He lost the most extravagant of his delusions first — viz., 
that he would be hanged for hurting his wife. By the way, he had, 
what I have often noticed in such cases, exalted ideas of the beauty and 
high qualities of his Avife and his children, and the greatness of his pre- 
vious position and prospects, all by way of contrast to his own misery 
and misdeeds. In six months he was quite well, and soon was able 
for hard work, which he did as well as ever, being able to make a large 
income. 

Now, the public and the friends of patients are very apt indeed to 
speak of such cases and treat them as if it was all the patients' fault, as 
if by a voluntary effort they could throw off such foolish fancies. One 
hears even doctors talking in the same way. They do not appear to 
understand how any one can believe such manifest, and what appears to 
them childish, nonsense about the state of the hypochondriac's health 
and organs, and yet be reasonable otherwise. I need hardly say how 
absurd such a view of the matter is. The two cases I have related show 
how such a condition is a real disease, beginning, running its course, and 
ending like many other diseases.^ The physiological view to take of such 
cases is that in them we have the brain-centres that preside over the 
great organic functions of alimentation and generation, etc., disturbed. 
When those functions are normal, and the brain is normal, the subjec- 
tive feeling is one of rest and satisfaction — one of organic pleasure. 
When the functions of those organs are interfered with, or have disease 
in them, we have a feeling of organic pain, but our convolutions being 
in good order, we do not put a wrong interpretation on the pain. W^hen 
the brain-centres that preside over those functions are affected by a dis- 
ease-storm, then, whether there is disease in the organs or not, there is 
often sensible disorder or lessening of function (as when the sexual ap- 
petite was paralyzed in A. L.), and the performance of function gives 
no sensible organic satisfaction. If the intellectual centres are also 
affected, we have the ill-being and pain misinterpreted and attributed to 
disease. 

All cases of hypochondriacal melancholia do not recover as those two 
did. My experience has been that this kind of case, when it occurs at 
the more advanced ages, is apt to be permanent, or the prelude to senile 
dementia. I had a medical man (A. M.) once under my care Avho was 
sixty, and who had exactly the feelings I have described, but who had 
no motor excitement, who would speak in the calmest manner possible 
about his feelings. He said that eating, though he had an appetite, 2;ave 
him no pleasure; that he had no sense of repletion, so that he had to 
stop, not because he felt he had eaten enough, but because ho saw he 
had eaten enough. He said that he had no comfortable satisfaction 
af^er his boAvels were moved; that he had no sexual desire or })owor 
whatsoever, which was true. He never recovered, and he never could 
be made fat, though every physiological and therapeutic fattener was 
tried. He said he felt all the time as if he had a paralvsis of tlio svm- 



72 STATES OF MENTAL DEPRESSION. 

pathetic in his abdomen. It was he who tried to poison himself with 
morphia. Certainly the cases who affirm they have no stomachs nor 
gullets, and that their bowels have not moved for years, etc., must have 
the subjective feeling somcAvhat the same as they would have if those 
things w^ere so. I have seen male senile hypochondriacs get very erotic 
mentally, with no sexual power. They would w^ant female nurses about 
them ; would have them wash and meddle with their organs of genera- 
tion; would wet and dirty the bed in order to be washed by a female 
nurse; have enemata administered, while all this time they would affirm 
that they had no stomach; that they could take no food; that their 
bowels were never moved ; and that they were so weak that any motion 
was an intense pain. 

That hypochondriacal delusions are determined at times by peripheral 
organic disease is, I think, sufficiently proved by pathological evidence. 
Many cases of hypochondriacal melancholia are caused by want of work, 
want of rational interest in life, by sluggishness of mind, selfish indul- 
gences such as well-off old bachelors practise, by over-eating and little 
exercise, by too routine modes of work and living. For these the treat- 
ment must be work and activity and change. I knew such a man cured 
by losing his fortune, and having to work hard for his living, and a 
woman cured by marrying a poor widower with seven children. I have 
known a mother cured by losing a child. In fact, every variety of 
melancholia is often cured by a great domestic loss, a real grief taking 
the place of and driving out the morbid mental pain ; but before this can 
occur, the nutrition must be improved. 

There is, of course, no dividing line between the hypochondriacal 
variety of melancholia and any other form. Especially it runs into that 
variety that I have called delusional melancholia, of which, in fact, it may 
be regarded as a less severe variety. When the delusions in that form 
refer to the bodily organs or the patient's health, it is difficult in some 
cases to say whether the word "hypochondriacal" applies or not. 

Delusional Melancholia. — By this term I do not mean melancholia 
with delusions. In that case nearly all melancholic patients would come 
under this class. I mean by it, that variety of the disease in which 
delusions, or a delusion, are from the beginning the most prominent 
mental symptom, in which those delusions remain throughout the disease 
of the same character, in very many being what are called fixed delusions 
in contradistinction to delusions that change in kind, or subject, or degree. 
As a general rule, in this variety of melancholia the delusion stands out 
so that the friends of the patient call it the cause of his disease, and say 
that if he could get rid of it he would be all right. It is the support on 
which all the mental pain and depression seem to hang. To those who 
do not consider the nature of the disease, the delusion seems the primary 
and causal event, the depression the secondary, and resulting just as 
when a prosperously happy man loses his wife and becomes sad : his loss 
is the cause of his grief. In some cases this may even be so, but in by 
far the majority of them the delusion and the depression are both results 
of the same cause, viz., constitutional disorder of the brain, that being 
developed out of hereditary tendency, and excited into action by periph- 



STATES OF MENTAL DEPRESSION. 73 

eral disease in some other part of the body, by blood poisoning, or by 
unphysiological modes or conditions of life. 

The delusions of melancholies are almost infinite in number and 
variety. I have had the chief delusions of about one hundred put down 
just as they were expressed to me (see p. 88). A sadder list of the 
causes of human misery, if they were real, it would not be easy to find. 
To the unfortunate men and women who hold these beliefs they are as 
real as if they had been true. They are enough to furnish another 
Dante with the causes of torture for another Inferno. It is true they 
were not all fixed delusions of the delusional variety of melancholia. 
To give a right idea of it, I shall classify the delusions somewhat, and 
give one or two cases representing each kind. The first kind of case I 
shall speak of, is that most nearly allied to the hypochondriacal last 
described, where the delusions refer to the patient's body or health, or to 
the performance of the bodily functions. These are very interesting 
from the physician's and the physiologist's point of view, for the one 
expects that by curing any bodily disease present, he will cure the 
delusion ; and the other finds in such a connection of mental disturbance 
with bodily disorder a sure proof of the relationship between certain 
parts of the brain and body. Not that we can in all cases demonstrate 
during life or after death such a direct connection. There is a very 
common kind of case w^here the delusions refer to the stomach and 
bowels ; I call them the visceral or abdominal melancholies. While they 
may be regarded as having something in common with the hypochon- 
driacal cases described, yet they are of a far more serious character. 
Their delusions are more intensely believed in, and the mental depression 
is much more profound. There are not only suicidal feelings and expres- 
sions, but serious attempts in many cases. The organic functions and 
appetites are far more interfered with. The appetite for food is paralyzed, 
and often that for drink. The sense of organic satisfaction in eating, 
digestion, and alimentation, generally is changed to one of uneasiness or 
pain. The patients thus get wasted. Sometimes real pain is felt in the 
abdomen. Many of them complain of an intense sinking at the epigas- 
trium, very like that w^hich combined hunger and fatigue produce in 
healthy persons. Some complain of a constant fulness in the abdomen, 
others of the disagreeable feeling that costiveness produces, others of a 
constant sensation of emptiness and faintness. The fiincies and delusions 
attached to, and arising out of, those real sensations are most various, as 
may be seen by referring to the list of melancholic delusions I shall give 
(see p. 88). All exaggerate their costiveness. All say their food does 
and will do them no good. They are so fiir right, that, put as much 
food as you like into their stomachs, it does not nourish as in health. 
Some say they have no stomachs, some no gullets. All say that the 
food will not digest. Some say they have foul breaths and smells from 
their bodies that make them offensive to those about them. Some say 
that they have syphilis ; some that they are being poisoned, indeed, this 
is common ; some, that the devil, or mice, or rats, or cats, are inside them. 
The sense of taste is certainly perverted in most of the cases, so that 
food tastes badly. 

All take food without enjoyment of it. Some take it only boeause 



74 STATES OF MENTAL DEPRESSION. 

they knoAv thev will be forced to do so if they refuse : while others resist 
any persuasion, and have to be fed forcibl}' by means of tubes i3assed into 
the gullet or stomach. Such, cases are often suicidal; they are always 
difficult to manage. They are all thin and sallow, and some of them die 
of starvation, with plenty of food in their stomachs. In some of the 
older cases there is a tendency to alternate constipation and obstinate 
diarrhoea. 

I had under my care in the Carlisle Asylum two most interesting cases 
(brothers), both of whom were visceral melancholies, and both of whom 
had the same delusions, viz., that their bowels were obstructed, etc. 
Dr. Campbell published an account of them,^ of w^hich this is an abstract: 

Two Cases of Visceral Melancholia {brothers). Delusions that their 
boivels IV ere never moved ; requiring forcible feeding ; death ; bile-duct 
found obstructed in one^ and large intestine constricted in the other. 

A. N. Admitted into the Carlisle Asylum on February 16, 1865. 
Male ; sixty years of age. 

No hereditary predisposition existed as far as could be ascertained, and 
this was the first attack of insanity. Mentally, he had, at the outset of 
the attack, been very dull and very hypochondriacal in his fancies. 
His bodily health had been tolerably good. He had been impulsively 
dangerous ; but had not attempted or threatened suicide. On admission 
he was found to be above the average height, well built, and in fair 
bodily health. Mentally he was very dull and desponding. His memory 
was good. He could speak coherently and answer questions correctly, 
but could not carry on a conversation owing to his always recurring to 
his bodily condition, which he described thus : that his belly w^as so 
much swollen that he could not take any food ; that he never got anything 
through him ; and that when he took castor oil it came aw^ay without 
moving his bowels. Nothing unusual could be discovered in the state of 
his abdominal viscera. 

April 1. — Mentally remains the same as at admission ; is in better 
bodily health ; works on farm. No one can speak to him or ask him a 
question without his saying — "I can't get aught through me. Will you 
give me some medicine ? I am about burstin'." His bowels, however, 
are regularly moved, and he takes his food fairly. 

July 1. — Little change ; at times refuses his food, saying that he is 
"bunged up." 

October 1. — A short time ago refused his food for three days, and had 
to be fed once with the stomach-pump. 

Little change is reported to have taken place in the mental or physical 
state of the patient for two years and a half, w^hen he had again on 
several occasions to be fed with tube, owing to his persistent starvation 
on the ground that his intestines were full. During 1871, on several 
occasions, he had to be fed. In 1872 he was most miserable in mind, 
frequently contemplated committing suicide, and at least on one occasion 
attempted to strangle himself. He wanted to hang himself with his 

^ Journ. Ment. Science Jan. 1875. 



STATES OF MENTAL DEPRESSION. 75 

braces, and on several occasions tore his rectum and anus most severely, 
thinking that this passage was shut up. He went about the wards shout- 
ing that he had "forty days' meat in his belly," that he was "bunged 
up," etc. ; and, if permitted, would spend most of the day on the water- 
closet, A dose of medicine always produced an alvine evacuation of 
normal color ; but, owing to the patient's dirty habits, and the practice 
which he said he was forced to, and which he termed "howking himself," 
the form of his stools could not be accurately ascertained. During this 
year both his ears became slightly swollen (the insane ear), then shrank, 
and became much misshapen. 

On October 16, 1874, having gradually got weaker, without any 
marked symptom of any special disease, he died. Almost his last words 
were that he had forty days' meat in his belly. 

Autopsy — Head. — There was an abnormally large amount of fluid 
under the membranes, and the convolutions were considerably atrophied. 
Section of brain showed it to be rather softer than normal. Sufficiently 
rich in puncta in some parts ; at base of brain it presented a slightly 
reticulated appearance from atrophy round minute vessels. The floors 
of the lateral ventricles were studded with small granulations. 

Chest. — In the lower lobe of the left lung, at its outer surface, there 
was a large vomica containing dark grumous fluid, and on the pleural 
coat of the lung there was, outside the cavity, some deposit of gray 
tubercle. 

Abdomen. — ^Liver normal ; duct from gall-bladder and pancreas 
patent. The gall-bladder contained a considerable amount of thin 
bile. Stomach normal — contained some food ; small intestine normal 
through its course ; large intestine contained a considerable amount of 
rather hard yellow feces. The large intestine, fifty inches from the 
caput csecum, and two and a half inches above the sigmoid flexure, had 
a very constricted part three inches in extent and six-tenths of an inch 
in diameter. Above the stricture the gut was two inches in diameter. 
The portion of gut below this to the anus was normal in calibre. 

A. 0. Admitted June 22, 1868, set. 61. No other hereditary pre- 
disposition as far as known, except that he is a brother of A. N. No 
cause could be assigned for the attack. He is stated to have been insane 
for two months ; previously he had been a steady, hard-working man. 
The first mental symptoms noticed were great dulness, hypochondriacal 
fancies ; latterly he had become worse — very melancholic and suicidal. 
He complained much of abdominal discomfort, indigestion, and costive- 
ness. On admission he was found to be a middle-sized man, old-looking 
for his age; his tongue clean. Temperature 97°. Pulse 60. Skin 
and conjunctivjTe slightly tinged yellow. Bronchitic rales heard over 
both lungs. Abdominal viscera seemed normal. INIentally was most 
dull and miserable, wringing his hands, complaining that he can get 
"nothing through him," tliat his "belly is much swollen," wisliing him- 
self dead, saying that he should be hanged, etc. 

July Sd.^Patient has been most miserable and dull since admission ; 
if permitted, would spend most of the day on the water-closet, trying to 
defecate, and, even after his bowels have been cleared out by the action 
of medicine, persists that they are full, that he needs medicine, and. 



76 STATES OF MENTAL DEPRESSION. 

though not so noisy as his brother, goes about complaining, in almost 
the same words, that he is ''bunged up," etc. 

He continued in the wretched mental state described up to October, 
1869. He had been treated with vegetable tonics and blue pill, frequently 
repeated, as it had been noticed that his stools were clay-colored ; and as 
his bowels were very costive, aperient medicine had been given him at 
intervals. He refused his food entirely on the 17th of October, saying 
he was going to burst, he was so full that he could get nothing through 
him, etc. He was fed twice a day with the stomach-pump up to the 
24th of October, when, owing to his most exhausted state, his struggling 
to resist the feeding, and especially his having almost died from suffoca- 
tion by the accumulation of mucus in his throat during paroxysms of 
coughing while being fed, it was deemed unsafe longer to feed him. 
Enemas were given him several times a day, and small quantities of 
liquid food were taken by the mouth. He sank, and died on November 
2, 1869. 

Autopsy — Head. — The whole brain was very oedematous. Fornix 
almost diffluent, and corpus callosum of both sides extremely soft. The 
optic thalamus of the left side was in a more softened state than the right. 
The cerebellum was abnormally soft and oedematous. 

Chest. — The lower portion of the lung was much congested, and con- 
tained innumerable small points of tubercular deposit. The lower lobe 
of the left lung was congested, and full of minute points of tubercular 
deposit ; its upper lobe was slightly congested, and contained a few de- 
posits of tubercle. 

Abdomen. — Liver slightly dark in color, otherwise appeared normal ; 
gall-bladder very small and shrunken, its walls were very much thickened, 
it contained a little black bile. The gall-bladder and pancreas had sep- 
arate ducts entering the duodenum, that from the pancreas entering 
lowest. The duct from the gall-bladder was not patent at its termina- 
tion ; it ended in a cul-de-sac of the intestinal wall. The wall of the 
intestine was thickened at this part, and looked like an ulcer inside of 
the intestine. 

These cases show that different kinds of abdominal distress and dis- 
turbed alimentation may excite the same delusion. Extreme constipation 
existed in both cases, but from quite different causes — mechanical ob- 
struction in the one, and lack of bile in the other. We know, of course, 
that neither constipated bowels, nor lack of bile, nor mechanical obstruc- 
tion, is necessarily followed by such mental delusions. For these we need 
something else, viz., brain convolutions predisposed to disordered action 
which results in a mental misinterpretation of real pain or organic dis- 
comfort ; and in those two brothers, though their family history was un- 
known, that cause of the insanity was no doubt present in the shape of a 
hereditary neurosis. One is justified in thinking that both causes were 
needed to produce the result in those men, who might have died reputedly 
sane but for the abdominal diseases which converted the heredity from a 
potentiality into an actual disorder. It will be observed that the brain 
in both cases presented signs of organic degeneration. 

There is no doubt a special tendency for abdominal and cardiac injuries 
and diseases to be accompanied by mental depression or a sense of vague 



STATES OF MENTAL DEPKESSION. 77 

discomfort, which is the opposite of the feeling of general well-being and 
organic satisfaction. 

The two following are cases where an organic lesion was found after 
death, that had evidently determined the character of the delusion : 

The first was a case of visceral melancholia, beginning as simple 
melancholia, then expressing religious delusions, then visceral delusions ; 
"no oesophagus;" refusal of food ; forcible feeding; death; intestine 
large, and scybala found almost obstructing bowel. 

A. P., set. 58. Disposition lively, social, cheerful. Habits active and 
industrious. Two previous attacks of melancholia ; one lasted about two 
years ; treated at home, and by change of residence. Paternal aunt died 
insane. Exciting cause not known. First symptoms : change of dispo- 
sition and habits, depression, inactivity, apathy, sleeplessness (treated 
with morphia). Recent symptoms : deep depression, despair, religious 
delusions, e. g.^ that there was no hope for her, that she had committed 
an unpardonable sin ; restless ; sleepless ; no attempt at suicide. Dura- 
tion of attack : two months. 

On admission, great depression, taciturnity, and delusions as to her 
spiritual state. She was quite coherent and free from excitement. 
Memory good. Physical condition poor. Nervous system and thoracic 
and abdominal organs apparently healthy. Appetite good. She slept 
little for nine nights, getting no' morphia, and missing it very much. 
Took sufficient food. Was quiet, reserved, and depressed ; thought her 
case a hopeless one. Considerable improvement occurred at first, and 
then greater depression and a change in the character of the case, the 
delusions now assuming the visceral character. Became restless, excited, 
and intractable. Said she could not live, and tried to strangle herself. 
Refused her food because she said she had no gullet. Grew steadily 
worse. Abdomen full, and a tumor was diagnosed. Persistently refused 
food. Had to be fed with nose-tube thrice daily, and very frequently 
vomited the meal. Bowels had been obstinately constipated ; laxatives 
and enemata being employed, caused unformed evacuations. Breath 
became extremely offensive, mouth covered with sordes. Died six 
months from beginning of attack, and four months and one week after 
admission to the Asylum. 

Autopsy. — Beyond very slight atrophy of the gray matter, there was 
no apparent brain disease. The thoracic and abdominal organs were 
healthy, with the exception of the intestines. The intestinal walls were 
greatly distended at different parts, the large intestine being particularly 
so affected. In the large intestine huge masses of hard fecal matter 
were found, which must have been there for a considerable time, judging 
from their appearance and the amount of irritation set up in the intestinal 
walls. On several parts of the internal surface of the latter there were 
pretty considerable extravasations of blood and traces of inflannnatory 
action. One huge mass of fecal matter seemed to block up the external 
orifice of the intestinal canal. 

Fortunately all such cases do not terminate in death, nor are they all 
accompanied by organic disease or obstruction of the viscera. i\lost of 
them are incurable, and yet after death we find no organic disease to 
account for the symptoms during life. Indeed, tliis is the case witli the 



I 



78 STATES OF MENTAL DEPRESSION. 

greater number of the typical cases. As the result of a statistical inquiry 
into this form of insanity, taking all the cases I had notes of, I arrived 
at the following results. In the first place, out of the visceral cases only 
one-fifth completely recovered, a few making a partial recovery, the acute 
misery and the delusions passing ofi", but some depression and some 
enfeeblement of mind remaining. Of those who recovered several 
relapsed into the same mental state at older periods of life, and then 
remained incurable. Another fact in regard to this disease came out in 
the statistics, viz., that every typical case was over fifty years of age. 
Some of the cases in which there was no organic disease found after death, 
had been characterized by a tendency to a sort of passive diarrhoea during 
the later stages of the disease, the best cure for which I always found to 
be the recumbent position. It seemed to be a diarrhoea from deficient 
motor innervation of the bowels — a sort of alimentary atony. This was 
usually accompanied by tissue wasting throughout the body, a low tem- 
perature, an incapacity to resist cold, a blue chilly state of the extremities, 
and a tendency to congestions, tubercles, and low inflammations. In 
fact, such conditions seem the natural termination of life in such cases ; 
or intercurrent diseases engendered by those conditions, such as bronchitis, 
catarrhal pneumonia, tuberculosis, gangrene of lungs, etc. 

The following is another very good example of this important and 
troublesome class of cases, there being present delusional melancholia, 
caused by exhaustion from over-work, the delusions being that all animal 
food given was human flesh, and was poison ; with refusal of food. Two 
attacks — first recovered from with perfect mental capacity for hard work ; 
second attack ending in death. 

A. Q., set. 50. At first attack, which consisted of mental depression 
and delusions that his food was "raw human flesh," so that he would not 
take it, he lost over two stones in two months the disease had lasted 
before he w^as placed under treatment in the Asylum. The cause had 
been mental anxiety and over-w^ork, and no heredity was admitted. 
The strange fancies of some melancholies were well illustrated by his 
imagining that the arrow on the paper in the crown of his hat had been 
put there to indicate that he would be put in a dark coal-cellar if he did 
not eat arrowroot ! He also believed his food was poisoned ; and he 
would not use the water-closet, as he imagined it would interfere with the 
drainage. He had cold hands and feet ; his skin was blue and cold ; he 
lost his big toe-nail from a chilblain ; and he had a boil on his face. He 
pointed to all these things in proof of his delusion that he had been 
poisoned. He had oxaluria, and his bowels were costive. He was fed 
well, got stimulants and fresh air, and gained in w^ eight ; but in seven 
months from the beginning of his illness he would still take no interest 
in anything but the state of his bowels. In about a year from the 
beginning of his illness he had recovered from his depression, and had 
got rid of his delusions, and he was strong and stout. In eighteen 
months he was doing an enormous professional business, implying the 
greatest mental strain, and the exercise of the highest intellectual ability. 
He did so for eight years, and then the symptoms, mental and bodily, 
that I have described came on again, and he had to be placed under 
treatment in the Asylum. This time he was over sixty. He was more 



STATES OF MENTAL DEPRESSION. 79 

emaciated ; he showed marked signs of arterial degeneration ; his prostate 
was enlarged, and his urine troubled him both by retention and inconti- 
nence at different times ; he was scarcely able to speak above a whisper ; 
and in his gait, attitude, and movements he gave the impression of an 
old man. In spite of every treatment — tonic, nerve-stimulant, fattening, 
and stimulant — he grew worse. He was compelled to take enough food, 
but it did not fatten him. He was constantly troubled with a mild 
diarrhoea, and he could not always keep himself clean. Whenever in any 
form of insanity the patient persistently passes urine, and especially 
feces, in his clothes or bed, it is a bad sign on the whole. It appears to 
imply always a profoundly diseased interference with the radical instincts 
of man. The only exception to this bad prognosis from this cause is 
when it happens in acute delirious mania and in stupor. The patient 
was removed home, and gradually sank in about nine months from the 
beginning of his second attack. 

Such a case shows that the morbid brain action, the trophic paralysis, 
the actual visceral derangement and its exaggerated mental representation, 
can all be recovered from. It also shows that there is liability to return 
with the decadence of function and degeneration of tissue of advancing 
life. As we shall see when I come to speak of the climacteric period and 
its characteristic mental disease, the great physiological crisis has much 
to do with such a case. Medicine, rest, food, fresh air, nursing, physio- 
logical conditions of life, can do much, but they cannot arrest the 
tendency to death inherent in tissue, and organ, and organism, when 
their appointed time of living has run. 

If we could connect the visceral delusions and depressions in every 
case with visceral lesions, as in the cases of A. N., A. 0., and A. P., we 
should place them in the clinical classification as visceral insanity. As 
we cannot yet say there is any visceral lesion or disorder at all in many 
of them, but merely a delusion that there is, I have simply described the 
clinical facts in regard to them, and avoided a new "form of insanity." 

The following was a complicated case of delusional melancholia, with 
one central and many peripheral causes of irritation and exhaustion, viz., 
a cancerous tumor of the middle lobe of brain, disease of kidneys, liver, 
pylorus, etc. 

A. Q. A., set. 58, a lady of good education, cheerful and frank dispo- 
sition, domestic and industrious habits, who had enjoyed good health, and 
had a family of several children. Temperament not neurotic. No 
hereditary predisposition to insanity. Predisposing cause of attack 
seemed to be domestic anxiety, and a sudden alarm of fire. Had been 
falling ofi" in flesh, appetite, and strength before mental attack, but became 
depressed some weeks before admission, and soon became possessed with 
the dehision that she was very wicked, that she had syphilis, and would 
infect those round her. She refused food, was sUx^pless, and imagined 
she had no passage in her boAvels. 

On admission there was extreme depression ; says she is very wicked, 
is lost, has syphilis, and is not fit to be here. Has an anxious, worn, 
pinched expression of face. Cannot be interested in anytliing outside 
herself. Memory seems fairly good. Is coherent, and can answer 
questions; very thin; color very bad. Has enlargeuiont of the thyroid 



80 STATES OF MEXTAL DEPEESSIOX. 

body, with prominent eyeballs. No paralysis or anaesthesia. Tongue 
slightly coated. Bowels very costive. Pulse 88, weak. Temperature 
98.3°. Patient was ordered a tonic — quinine and hydrochloric acid — 
and to have two glasses of sherry daily, with good nursing, and plenty of 
easily digested food and fresh air. 

For a time patient showed a slight improvement, but this proved very 
temporary, and the melancholic condition became aggravated. She slept 
badly, occasionally having a good night, but generally being restless, 
with broken, disturbed sleep. The appetite was much impaired, patient 
taking very little food, and ultimately refusing food altogether, so that 
on one occasion she had to be fed with the stomach-pump. The tongue 
was clean, but dry ; the bowels were costive, and had to be regulated by 
occasional doses of compound licorice powder and other aperients. Patient 
had a pinched, anxious expression of face, and lost flesh. Mentally she 
was in a condition of great depression, with numerous delusions of a 
melancholic character. She fancied that she was lost to all eternity, 
that she had misconducted herself in youth, and that she Avas now suffer- 
ing from a disease which she had contracted at that time ; that she had 
ruined her husband and family, and that there was no place for her at 
home at all. Along with this there was considerable enfeeblement of 
mind ; she was childish, querulous, and unreasoning in her conduct ; and 
her power of attention and her memory were much impaired, especially 
as to recent events. After having been in the asylum for weeks, she 
would maintain that it was only one long day since she came ; she com- 
plained that the days never came to an end, and that she was compelled 
to take an extraordinary number of meals in each day. This perversion 
of the sense of time and number is not uncommon in melancholia. When 
asked to go to dinner, she would querulously reply that it was not half 
an hour since she had taken breakfast. She showed little interest in 
what passed around her ; could be got to take little or no part in work 
or amusements, but was always harping upon her own miserable condi- 
tion, and in conversation giving ready expression to her delusions. She 
was very disinclined to take the usual open-air exercise, and would meet 
the doctor on his morning visit with the constant request that she should 
be allowed to remain in the parlor, as she was too weak to walk. When 
compelled to go out, she thought that she was being treated unkindly, 
and this idea at times almost amounted to a delusion that she was per- 
secuted by the attendants ; and when visited by her friends she would 
frequently make ungrounded complaints against them. 

With occasional slight variations from time to time, patient's mental 
condition during the winter continued much the same as that noted above 
— depression and enfeeblement, with delusions of a melancholic type. 
But during all this time her physical health was steadily deteriorating ; 
she took her food badly, and only with much coaxing (though the 
stomach-pump did not again require to be used) ; she was restless at 
nights ; the bowels were still costive more or less. There were great 
emaciation, a slightly jaundiced tint of the conjunctiva, and a markedly 
cachectic appearance, such as to make one at once suspect that the patient 
might be laboring under organic, and possibly malignant, disease. From 
time to time repeated physical examination of the thorax and abdomen 



STATES OF MENTAL DEPRESSION. 81 

was made, with the object of detecting any organic disease that might 
exist, but no evidence of such disease could be found. Beyond frequently 
containing a very large quantity of urates, the urine, indeed, usually 
showed nothing abnormal. It was difficult to make a satisfactory ex- 
amination of the organs, as the patient complained bitterly whenever she 
was touched, and her statements as to the parts in which she felt pain or 
tenderness on pressure could not be relied on. Great oedematous swelling 
appeared in the feet, and gradually extended up the legs. The pulse 
became small and very thready, and latterly could sometimes scarcely 
be felt at the wrist. The bowels at this time were much more regular 
than previously, and the stools more natural in appearance. Patient 
grew weaker and weaker, and ultimately sank, a year after admission. 

Autopsy. — Body much emaciated ; extensive bed-sore over sacrum. 

Brain. — Vessels at base atheromatous. Vertex healthy looking. 
There was a tumor, the size of a hen's egg, growing from the upper part 
of petrous portion of the left temporal bone, weighing half an ounce, and 
attached to the inner table of the bone, which was somewhat softened. 
The tumor was encysted in the brain matter, but not attached to it, lying 
quite free in a cup-shaped cavity. The contiguous brain substance was 
flattened out and somewhat softened. 

The cancerous mass, on microscopic examination, was found to consist 
of small cells lying in the meshes of a delicate stroma, although much 
resembling brain matter, but distinguishable from it by the absence of 
the characteristic larger brain cells of the gray matter. The brain was 
softened near the tumor, and very anaemic. 

Abdomen. — There were several small secondary masses of cancer at 
the pyloric end of stomach, the orifice of which was constricted. No 
secondary cancer in liver, kidneys, glands, or other organs. The splenic 
artery was enormously tortuous and dilated. Liver was fatty, with 
thickening of the coats of its arteries and bile-ducts, and considerable 
increase of fibrous tissue round them. The fibrous tissue round the bile- 
ducts was deeply stained with bile even to the smallest duct. 

Kidneys. — Right kidney full of very large cysts; substance otherwise 
normal. Left kidney had marked cystic degeneration. The renal sub- 
stance was almost gone, its place being taken by numbers of cysts, many 
of them containing dark fetid fluid matter. 

In regard to the duration of each of the distinct diseases, the only 
guides one has in forming an opinion are the pathological appearances 
after death. Not one of them produced unequivocal symptoms during 
life by which they could have been certainly diagnosed, or their course 
determined. The cystic condition of kidney seemed undoubtedly to have 
been the first departure from health. But then, on admission, it did not 
cause albuminuria, (Bdema, or any other symptoms referable to renal 
diseases. It was only, in fact, within two months of deatli that this was 
so. The contraction at the pyloric orifice of the stomach must have 
existed some time, but there are no data for saying how long. There is 
fair reason, however, for connecting this with the loss in flesh, fallinjj oft 
in appetite, and discomfort in tlie region of the stomach and bowels, 
which came on a few months before the insanity. The liver had clearly 

6 



82 STATES OF MENTAL DEPRESSION. 

been disordered in its functions ; and obstruction of its ducts had been 
suspected by us during her disease, and the urine examined for bile, just 
a trace being once found in it. In fact, I had a strong suspicion of ob- 
struction of its ducts, irom the mental symptoms being similar to those 
of A. N. and A. 0. (pp. 74 and 75). 

The cancerous tumor of the brain had been utterly unsuspected, and 
had produced no symptoms discoverable whatever, either sensory or 
motor. Such a tumor as that, I cannot imagine would have grown to 
such a size within the skull, where there is so little room for ready ex- 
pansion, in less than twelve months, and probably it took a longer time 
than that. My experience of such tumors would lead me to say that its 
duration was over a year. 

The cause of death in this case was really the exhaustion and failure 
of bodily nutrition, caused by the presence of all the diseases and morbid 
states of mind and body. Their combined evil efiects had reached that 
point which was incompatible with life. 

• The mental symptoms were from the beginning, in many respects, of 
that type of melancholia which has been associated with disorders or 
diseases of the alimentary canal. The cry of the organism for suitable 
nutriment, which is revealed to consciousness as appetite, w^as quite 
abolished, and there was instead, at one time, a strong repugnance to 
food. Digestion was impaired. There were clearly strong feelings of 
organic discomfort after eating. The bowels were very costive, and her 
delusions exaggerated their costiveness into months between each move- 
ment. Her abdomen and abdominal muscles felt hard and stretched. 
The hypera&sthesia she had was referred for the most part to her bowels. 
With all this there was extreme emaciation, though plenty of nourishment 
was taken into the stomach. 

I think one may confidently refer the direct cause of the special delu- 
sions in all those cases to a disordered working of that portion of the 
brain which presides over the function of alimentation ; and, secondarily, 
to a disordered working of the organic nerve ganglia that so abound in 
the abdomen — the sympathetic system of nerves, the semilunar and 
visceral ganglia, and the small nerve ganglia in the coats of the bowels. 
Ferrier thinks that the posterior lobes of the brain are the seat of the 
organic brain functions, but there is no proof of this, and the lower 
portions of the middle lobes are yet quite unappropriated as to special 
functions. It may be that their functions are those of presiding over 
and regulating alimentation and digestion. The real cause of the aboli- 
tion of the normal food appetites in so many diseases and states of dis- 
ordered health, and their perversion in other instances, is unknown, but, 
beyond a doubt, we must refer many of them to some central cause in the 
brain. The whole of A. Q. A.'s case was interesting from there being 
disease in the brain which probably caused the melancholia, and disease 
in the abdominal viscera which determined its special character and its 
delusions. 

In two very marked visceral cases of melancholia, with delusions of no 
stomach and intense repugnance to food, I have had the semilunar, and 
many of the sympathetic ganglia of the abdominal plexus taken out, 



PLATE VTI. 




James Robertson Del* 



G V/ater Stan St Sans, Litho Edinburgh 



STATES OF MENTAL DEPEESSION. 83 

hardened, and cut into sections, and examined them microscopically, and 
in both cases I found the nerve-cells markedly degenerated, atrophied, and 
pigmented (see Plate VII., Fig. 1). Some of the cells had almost disap- 
peared, and very few of them in any of these sections were normal. 
Whatever are the precise functions of those ganglia, beyond a doubt they 
could not have been properly performed by those diseased cells. 

The delusions refer to electricity or some such imaginary source of 
annoyance in a large number of instances, as in this case, which recovered : 

A. R., set. 44 ; education average. Disposition reserved, unsocial, 
suspicious, grasping ; habits steady and industrious. One previous 
attack of depression with delusions lasting a month ; treated and cured 
by travel and rest; no insanity in family. Exciting cause: over-work 
and business anxiety. Attack has lasted one month, though he had 
been dull before. Became restless and sleepless ; lost appetite ; very 
depressed ; threatened violence to himself; was very suspicious, and abso- 
lutely possessed with the delusion that an electric battery was at work in 
his house acting on him, and causing pain and sleeplessness. On admis- 
sion, great depression shown in expression, language, and behavior. 
Talks all the time about people working on him with an electric battery 
in his bed, and that enemies are conspiring to ruin him. General health 
weak; condition poor; tongue foul ; bowels costive; conjunctivae yellow^ ; 
muscles flabby. For a week after admission he remained extremely 
depressed, reserved, full of the battery delusions, and suspicious, and 
slept very little. Under light digestible food and milk, tonics, podophyllin 
every night, fresh air, and constant companionship, he improved steadily, 
became more cheerful and sociable, talked less of the delusions, slept 
better, and had a good appetite. Within three months he was able to 
live in one of the detached houses ; and in two months more he was dis- 
charged recovered, having gained a stone and a half in weight, looking 
fresh, and mentally quite happy. During recovery he passed through 
the common enough stage of belief in the existence of the battery at one 
time, though he said it was not worked on him then. After complete 
recovery he laughed at the whole idea as being a morbid fancy ; but he 
said his sensations had been most uncomfortable, that he used to feel 
sudden pains, to twitch and jerk and jump up in bed, and had imagined 
those motor and sensory nervous symptoms meant that he was worked on 
by a -battery. The pathological explanation of them is no doubt this, 
that through brain disorder or peripheral disease, neuralgic and perverted 
sensations are felt, and their meaning misinterpreted by the disordered 
intellectual centres, which are at the time not in a condition to be affected 
by evidence, or capable of reasoning rightly. I once had an epileptic 
patient who, at times after the regular fits, used to twitch in her limbs, 
and who would point to the twitchings (that were evidently accompanied 
by pain) and say — "Look how it works on me," meaning that some one 
was electrifying her. Such delusions of annoyance or being worked on 
by electricity, magnetism, or unseen agency, if they last long, while the 
depression abates, are very unfavorable as regards prognosis. But, so 
long as there is distinct depression, of which these delusions are an 
accompaniment, the case sliould be held to be curable, and treated as such. 



84 STATES OF MENTAL DEPEESSION. 

There is a popular notion that religious cases of melancholia are very 
unfavorable. It is meant that cases with intense despondency as to their 
religious condition, and delusions as to their eternal damnation, — as to 
having committed an unpardonable sin, having offended the Holy Ghost, 
having led most wicked lives that will never be forgiven, having failed to 
instruct their children properly in religious truths, having caused much 
sin in others by their example, having neglected the services of religion, 
having been hypocrites and impure in heart and motive while professing 
Christianity, and kept up religious appearances so as to deceive the 
world, being possessed by the devil, etc., — that such cases never get well. 
No doubt there are some bad cases of religious delusional melancholia, 
and such patients are apt to make a strong impression on those who see 
them. In reference to them, the religious superstitions of the Middle 
Ages as to diabolic possession still cling in the popular mind. They are 
always taken to the clergy first for comfort and spiritual help. It is 
difficult to draw the line, too, between them and the religious ''conviction 
of sin" and doubt and depression which, according to many systems of 
theological belief, are a normal part of the individual religious life. 
John Bunyan's prolonged depression and ''darkness," which is accepted 
by many as a normal religious experience, having no connection what- 
ever with mental disease, is sufficiently like some of the cases to cause 
a feeling of confusion about them. Some of the cases have been called 
by special names — Demonomania, etc. There is no doubt, too, that 
the religious instinct of man is one of the deepest and most central 
parts of his psychological constitution, and is often cultivated and devel- 
oped from childhood in a way that few of his other faculties are ; so that, 
when perverted, it causes intense general emotional disturbance. These 
reasons are sufficient to account for the general idea that the prognosis in 
religious insanity is bad. But, as a matter of fact, this is untrue. A 
very large number of cases of melancholia have a religious element 
in them, and it certainly does not prevent them from getting better. 
The following is an example : 

A. S., net. 29. Disposition cheerful. Habits industrious. Comes of 
an excitable, eccentric family. Cause of her illness ill-treatment by her 
mistress and amenorrhoea. First symptoms, mental confusion and 
depression, and falling off in bodily looks, appetite, strength, and her 
head feeling '"queer." On admission she had mental depression, as indi- 
cated by her expression, attitude, and the general tone of her conversa- 
tion. There was also slight mental enfeeblement : her memory seemed to 
be greatly impaired. She labored under various delusions of a religious 
kind, e. g.^ that she was the greatest sinner alive, and had committed 
many and unpardonable sins. She wore a very dejected aspect. The 
sensory functions were slightly dulled, and the reflex functions impaired. 
She had suffered for several months from amenorrhoea. She was very 
suicidal. She was the very picture of misery, despair, and lack of 
interest in the world outside her. 

She was put upon sulphate of quinine and iron, and aloes, good food, 
and fresh air and employment, which she was not at first able to settle 
herself to do. At first there was no change for the better. Was very 



STATES OF MEKTAL DEPRESSION. 50 

depressed; refused food, wept causelessly at frequent intervals, and 
generally bemoaned her lot as being a castaway from God. Became dis- 
tinctly worse mentally. Had hallucinations of hearing. Still refused 
her food. In two months had greatly improved in her mental and bodily 
condition, and took her food, but was at times obstinate and wayward. In 
five months, menstruated for the first time since admission, and at once 
her mental recovery was completed, and she said she felt quite differently. 
She had got stronger, stouter, and better looking before, but the change 
after menstruation was marked and immediate. The sense of religious 
depression and despair disappeared, and she was cheerful ; and religion 
did not trouble her much one way or the other. 

In this case she had been brought up in a religious sect where, theo- 
retically, religion was all in all. When she was miserable, what would 
so naturally fix her morbid ideas as to the cause of her condition as the 
religious ideas in which she had been educated ? but they in no way 
afiected the progress or the favorable result of the case. 

There are some cases of religious delusional melancholia where the 
depression is certainly very intense, the mental pain most deep, and the 
prognosis very bad. Some of those are persons with the combination of 
a highly-developed religious instinct and a strongly-marked heredity to 
insanity. If, along with those t^o conditions, life is on the wane with 
the patient, and decadence of weight and general vigor has begun, and 
religious delusional melancholia comes on, the outlook is often bad. The 
following is an example : 

A. T., set. 45. No children. No heredity to insanity acknowledged 
by relatives, but this I had reason to doubt. Temperament melancholic 
and diathesis nervous, but disposition had been most cheerful and benevo- 
lent ; habits active, especially in doing good, teaching classes among the 
poor, and comforting the afiiicted. A particularly bright, cheery woman 
when well, happy in her religion. She went to a trying climate about a 
year ago and got a little run down. A few weeks before I saw her she 
had become dull and lost her brightness and vivacity. She said she had 
lost her "hope in God," and her comfort and assurance in religion. She 
thought God had forsaken her, that she was lost, that her former re- 
ligious life had been tinctured and polluted by selfishness of motive, and 
that she had been a hypocrite before God and man. She would not go 
to church, and any attempt to administer religious consolation to her in 
the usual way by clergymen, engaging in religious exercises with friends, 
quoting suitable texts, etc., only made her worse. " Those are not for 
me," she would say. " I would insult the Almighty more and more by 
going to church." Her subjective mental pain entirely prevented her 
from being able to see the cheerful aspects of the Christian religion. 
With these mental symptoms there had been headaches and strange 
feelings in the head to begin with, but these passed off, as is very 
common, when the affective mental symptoms developed themselves. 
But there was a furred tongue, that had been most wrongly treated by 
purgatives. When will our profession fully understand that a man's 
tongue may be as furred and foul from want of food, or from an atonic 
innervation of the stomach and bowels, or from a mere neurosis, as from 



86 STATES OF MENTAL DEPKESSION. 

sluggishness of the primoe vice ? She was menstruating irregularly. She 
looked haggard and flabby. She had lost her feminine plumpness, and 
her weight was much less than it had been in health. Her food-appetite 
was paralyzed, eating giving her no pleasure. I prescribed nitro-muri- 
atic acid and quinine mixture ; fattening diet, taken little and often ; 
simple warm water enemata for the bowels ; change of scene among 
intimate friends ; stopped the knocking about in travel that she had been 
trying ; proscribed religious talk of any sort, and gave directions for her 
being watched at all times. But she steadily got worse, more sleepless, 
more restless and agitated, and more miserable, till she was the picture 
of despair ; became distinctly suicidal ; had to be sent to an asylum, and 
in two years she passed into dementia with still a melancholic tinge to it, 
as is usual in the dementia that follows melancholia. 

This case is the common type of religious delusional melancholia, but 
there are persons with religious melancholia of a far more subtle type 
than this — persons of a neurotic diathesis, lively fancy, delicate feeling, 
and keen religious sentiment that has been developed by much fostering 
care from their youth up ; persons who have had many of the functional 
neuroses, martyrs to headaches, varied by spinal irritations ; in torture 
from neuralgia one day, and roused by mild hysterics the next. They 
are clergymen's spinster daughters, or the female members of intellectual 
and religious families. They suffer much, but they generally suifer it 
patiently. The depression of feeling with them is usually hung on some 
subtile controversial or doctrinal peg, or on an ethical or religious point, 
so fine that it seems to a healthy mind almost ridiculous to regard it as 
of any importance. Such persons at times undergo temporary paralysis 
of religious feeling and volition, " deadnesses," and they torture them- 
selves about it. Jhose people are all thin, and to them I preach the 
gospel of fatness, the gospel of fresh air, of healthy secular literature, 
and active occupation, of iron and quinine, and a little bromide of potas- 
sium when needed. 

In some cases of delusional melancholia, the delusions refer to ridicu- 
lously paltry things. One young man, A. T. A., once consulted me 
on account of his depressed condition, and the great depression under 
which he labored was caused, he said, by his having joined the Conserva- 
tive Club in his- native town without consulting his father. A woman 
hung her depression on the peg that the marriage ceremony in her case 
many years previously had not been properly performed in some minute 
particular. Dozens of patients have assigned to me as their unpardon- 
able sin that they had occasionally practised masturbation. Patients 
torture themselves about events in their lives that no one else can see to 
be of any import whatsoever. ' In some cases the patients transfer their 
own disease in delusional imagination to those near and dear to them, 
and are most depressed about it, e. g.^ I have a woman now^ who says her 
husband is very ill, that he is "dull in his mind, poor fellow, and I wish 
you would cure him." 

The following is a case of delusional melancholia, w^here the delusions 
seemed at first sight " fixed," but where recovery took place satisfactorily : 

A. U., eet. 36. Disposition reserved and quiet, but not melancholy. 
Nervous diathesis. Habits industrious. Sister ineurablv insane, and is 



STATES OF MENTAL DEPKESSION. 87 

in an asylum. Father had an attack of a month's duration. The ex- 
citing cause of the attack had appeared to be the death of a near relation 
of her husband, whom she had helped to nurse. The first mental 
symptoms were depression of spirits and sleeplessness. She soon ex- 
pressed the insane delusion that she had been the cause of ber brother-in- 
law's death, through having had improper thoughts and conduct towards 
him during his life. This she talked of from morning till night, in fact 
would speak of it to strangers, and would talk of nothing else ; when 
pressed, her improper conduct was found to have consisted in smoothing 
his hair when he was lying in bed very ill, and even that may not have 
been a fact. She would not employ herself, lost all interest in her work, 
or in anything. I saw her in consultation, and advised a good trained 
nurse, change and travel, and visiting near relations. But she got 
steadily worse, and was very obstinate indeed, and would take no medi- 
cine. Thinking that perhaps some uterine disease or disturbance might 
be present, and determine the character of her delusions, I wished her 
examined, but she would on no account consent. She ate heartily, and 
looked fat and well. She made one or two futile attempts at suicide by 
twisting her hair round her throat. When well, she had been a bright, 
agreeable looking woman ; when suffering from this illness, her ex- 
pression of face was totally changed. One would scarcely have known 
her to be the same woman. This absolute chano;e and reversal of the 
characters of the facial expression is most marked in such melancholia. 
She had to be sent, after about three months, to one of the villas attached 
to the Asylum, and for the first Aveek she did nothing but repeat her de- 
lusion and fret about it ; she thought of nothing else. She took up the 
idea then that she ought not to have left home or come here. She was 
sleepless and restless at night, and very obstinate. She got tonics, lived 
in the fresh air, and walked long distances each day with her attendants; 
ate well, and got forty-five grains of bromide of potassium at night. She 
improved for three weeks and then had a relapse during menstruation, 
which was very abnormally scanty. She felt as if she had a shock on 
her head one night, and after that she felt as if her brain was " completely 
gone." Such neuroses of sensibility are very common in melancholia,, 
and this feeling as if the brain was "gone" is particularly so. I suppose 
the patients are conscious of a mental incapacity, a paralysis of thinking 
and volition, along with a strange feeling in the head, and that this is the 
foundation of this delusion. After this she chano;ed somewhat. She 
was more obstinate and very sleepless, and unable to read or employ 
herself; but, instead of having caused her brother-in-law's death, she 
began to blame herself for having left home and her husband, and harped 
on this from morning till night, reproaching herself for what she had 
nothing to do with. I looked on this change of delusion as a very good 
sign, and my prognosis was better after that. She menstruated regularly 
but scantily, as slie had done from the beginning of the attack. She was 
put on dialyzcd iron, aiid got it steadily tliereafter. In four months there 
was a very great im]irovemcnt, and in six months she was well enough to 
go homo, and completed her recovery there, having gained about a stone 
in weight during her convalescence, though she was never thin from the 
beginning. 



88 STATES OF MENTAL DEPRESSION. 

Next to the convulsive and organic varieties of melancholia, the de- 
lusional is the least hopeful as regards recovery. 

The following are actual examples of delusions of about one hundred 
.female melancholic patients, and they far from exhaust the list: 

Delusions of general persecution. 

" " general suspicion. 

" " being poisoned. 

" " being killed. 

" " being conspired against. 

" " being defrauded. 

" " being preached against in church. 

" " being pregnant. 

" " being destitute. 

" " being followed by the police. 

'' " being very wicked. 

"■ " impending death. 

" " impending calamity. 

'' " the soul being lost. 

" " having no stomach. 

" " having no inside. 

" " having a bone in the throat. 

" '' having lost much money. 

" " being unfit to live. 

" " that she will not recover. 

" " that she is to be murdered. 

" " that she is to be boiled alive. 

" " that she is to be starved. 

" " that the flesh is boiling. 

" .. " that the head is severed from the body. 

" " that children are burning. 

" " that murders take place around. 

" " that it is wrong to take food. 

" " being in hell. 

" " being tempted of the devil. 

" " being possessed of the devil. 

" " having committed an unpardonable sin. 

" " unseen agencies working. 

" " her own identity. 

" " being on fire. 

" " having neither stomach nor brains. 

" " being covered with vermin. 

" " letters being written about her. 

" " property being stolen. 

" " her children being killed. 

" " having committed theft. 

" " the legs being made of glass. 

" " having horns on the head. 

" " being chloroformed. 



STATES OF MENTAL DEPRESSION. 89 

Delusions of having committed murder. 

" fear of being hanged. 

" being called names by persons. 

" being acted on by spirits. 

" being a man. 

" the body being transformed., 

" insects coming from the body. 

" rape being practised on her. 

" having venereal disease. 

" being a fish. 

" being dead. 

" having committed '' suicide of the soul." 



LECTURE III. 

STATES OF MENTAL DEPRESSION— MELAifCHOLIA 

{PSFCHALGIA)—CoNTmjj^T>. 

Excited (Motor) Melancholia. — This, like all the other varieties 
of the disease, may be one stage in the complete clinical history of a case, 
or may be the type from beginning to end. The motor centres are 
evidently affected to a greater extent in this than in any of the other 
varieties, except the one I shall describe as the melancholia with epilepti- 
form attacks. The patients rush about, are violent to those about them, 
wander ceaselessly, w^alking up and down like tigers in a cage, or roll 
about on the floor, or wring their hands, or shout, or groan, or moan, or 
weep loudly, or tear their clothes, or in their cries, attitudes, and motions 
express strongly their mental pain. In short, the muscular expression of 
the pervading emotion is strong and uncontrollable by volition. Some of 
the very worst and most incurable cases of melancholia are of this type — 
certainly the most troublesome to manage. The motor expressions are 
pirtly determined by the intensity with which theadeg-motor centres are 
affected in the brain, and partly by the amount of inhibition possessed by 
the individual when well. Women very frequently present the motor 
type of the disease. The Celtic race does so markedly. The wailing 
and weeping, the gesticulations and motor grief of an Irish woman are 
usually out of all proportion to the mental pain — that is, if we take the 
Teutonic type as our standard. Here is an example : 

A. v., set. 28, an Irish woman. Patient had been confined a week 
previous to admission. The day before her admission she suddenly be- 
came very unsettled and careless about her child ; she also attempted 
suicide. On admission she was greatly depressed ; she confessed to 
feeling exceedingly miserable, and could only be got to answer the 
simplest questions with difficulty ; she had a woe-begone appearance, 
and her bodily health was very weak. She slept very little the first 
night, but seemed considerably better next day : conversed readily and 
cheerfully ; said she felt much better, and that her strange behavior pre- 
vious to admission was due to something which came over her and con- 
fused her. 

In a week she got worse, being much depressed ; thought she was to 
be killed, and that everything was going wrong with her ; did not take 
her food well ; attempted to drown herself by jumping into the asylum 
shallow curling pond. 

In a month she was somewhat improved, but still continued much de- 
pressed in mind. She did a little work. In six weeks, after seeming to 
improve for a time, patient relapsed. She became the embodiment of 
utter misery and wretchedness, which she exhibited in a most demonstra- 



STATES OF MENTAL DEPRESSION. 91 

tive way. She wrings her hands ; swa3^s backwards and forwards, con- 
torting her body ; rushes about from place to place, and cannot settle for 
a minute. But the most striking things about her are her countenance 
and the noises she makes. She has a large mouth, and as her v. sage 
assumes the most doleful aspect, expressing the intensest misery, her 
mouth begins to open until it is a great gaping cayern, and she howls — 
" Oh, John, dear ! doctor, darlin' ! and me childer ! and me persecuted 
in this jail ! oh, I'm punished ! dear darlin' doctor ! oh, me two brothers ! 
oh, kilt and murdered they are ! Oh ! oh'! oh ! " All this time there is 
seldom a tear, and it goes on from morning till night, and sometimes all 
night, so that you cannot hear yourself speak within ten yards of her. 
Though the misery is most real to her, yet the effect is often very ludi- 
crous, as if you were looking at the overdonfe misery of an Irish wake on 
the stage. She ate well, and her bodily health improved, though she had 
prolapsus uteri, for which no treatment could be adopted. 

Here is a chronic case of the sort that has gone on for years : 

A. W., 9et. 45, deaf and dumb, who was educated. A relative is in- 
sane. 

For four years now he has been in his present condition, Avhich to all 
outward appearance is that of misery, as great as any painter has ever 
depicted as the lot of the damned in hell. He is never at rest, but paces 
about with an uneasy, nervous gait. His hands are always moving, tear- 
ing his clothes or unbuttoning them, or masturbating, which he does in 
the most shameless open way ; indeed, he is doing it half the time. He 
makes a hideous noise nearly all the time between a groan and a hiss, 
and his expression of face is that of absolute misery and desperation. 
At times he rushes about, and if any one comes in his way he knocks 
him down ; in fact, he has a distinct homicidal impulse, which makes 
him attack those near him. At times he tears his flesh and beats his 
head. He seems to feel no pain. He is the worst patient in Morning- 
side Asylum, and, in fact, is about the worst I have ever seen, taking the 
long time he has been affected into account. Everything has been tried 
in vain for his recovery and amelioration. Nothing will interest him ; 
scarcely anything will quiet him. I have tried hyoscyamine, and it 
nearly poisoned him. I gave him bromide of potassium in doses up to 
six drachms a day. I tried cannabis Indica with it, and he merely fell 
off in flesh, without being benefited. He was walked in the fresh air till 
two strong attendants were done up. He was tried to wheel heavy bar- 
rows of soil, but the fight to get him to do so threatened to run some 
risk of killing him. I only wish I could castrate him, for the constant 
masturbation, or attempt to masturbate, seems to show that the centres 
of generation are in a state of morbid excitation, and I think it might 
do him good. 

This is another chronic case of motor melancholia, which is very com- 
mon in old age : 

A. X., net. 77. Single; gentlewoman. Disposition active, but pas- 
sionate. First attack. No exciting cause Known. Had a fall down 
stairs six months ago. Became very restless and slee})less, and lost appe- 
tite. This condition has lasted for three months. 
■ On admission she was very depressed and unsettled. Could not sit 



92 STATES OF MEXTAL DEPEESSION. 

do-wD or rest for a moment. Walked about the room the picture of de- 
spair, and took no interest in anything. Was enfeebled in mind, and 
behaved in a silly, miserable way. Her physical condition and general 
health Avere poor, and she was very anxious about her state of health and 
her soul's salvation. She had no sleep the night after admission, and 
was very noisv and restless. She was very depressed : be^sed to be 
sent home : wrung her hands and wept. This continued with little 
change. Her nights, with few exceptions, were sleepless, unless narcotics 
were o^iven : and she was also verv noisv, beatins: at her bedroom door 
and shouting loudly. During the day she was in a constant state of 
miserable unrest. She was suspicious and despondent ; said she wished 
she were dead ; refused her food ; would not settle to any work. This 
state of unhappy restlessness and excitement became fixed and chronic, 
while her mind became more enfeebled. She got plenty of food, but 
never could be fattened. After three years she began to show distinct 
signs of partial hemiplegia, which was first on one side and then on the 
other, each attack passing off in a few days. Two of my former assist- 
ants, Drs. Hayes Xewington and J. J. Brown, have described this con- 
dition and its pathology, attributing it to capillary apoplexies, as are 
shown in Plate YIL, Fig. 2, occurring in succession.^ But she could never 
sit down for any length of time till near the very end, a year after the 
commencement of the paralysis, when she went to bed and soon died. 
She would eat her meals standing and moving. She swore and used 
blasphemous language to herself. She said she would ''burst" if she 
was made to sit down. The convolutional motor excitement was un- 
ceasing, and nothing could exhaust it. It was connected with the decay 
and defeneration and atrophy of the brain in old ao^e — a lono^-continued 
brain storm that ended only with life. Such old people are most difficult 
to treat. If we, by mechanical means, restrain their motions, my expe- 
rience has been that it is no conservation of energy, but the excitement, 
finding no motor outlet, reacts inwards and makes the mental state much 
worse. 

When insanity in boys and girls takes the melancholic form, it is 
usually attended by much motor excitation, especially weeping — the 
boyish mode of expressing grief. This is an example : 

A. Y.. cTet. 12. Disposition: old-fashioned, sedentary, excitable, 
thoughtful, and studious for his age. Several brothers and sisters died 
in infancy of head affections, and a paternal uncle had been melancholic. 
Mother nervous and eccentric. Father died of consumption. Had been 
brought up in a poor way with an old grandfather, with whom he lived 
alone, living on tea and coffee and no milk. Had not romped and played 
enough. Had been in the habit of wetting the bed. His father died a 
few months ago. Seemed to feel it as a man would, and has never been 
the same since. Of late has dreamed much, and awoke in the middle of 
the night. Has been at school, and did well. Last week the school- 
master checked him for holding his pen the wrong way. He came home 
agitated, nervous, depressed, and confused. Talked all night in an inco- 
herent way of holding the pen, etc. He has got worse till he is now 

1 Edin. Med. Joum.. August, 1S74. and Journ. of Mental Science, July, 1877. 



STATES OF MENTAL DEPRESSION. 93 

much depressed ; crying, sometimes with tears, sometimes without, all 
the time. (By the way, melancholies are by no means always tearless. 
I have one now who literally weeps floods of tears.) He was most rest- 
less, sleepless, appetite gone ; was flabby, with great dilated pupils ; a 
temperature of 98°, and a pulse of 106, and weak. Under tine, bella- 
donse gtt. x. and potass, bromid. gr. xv. twice a day, fresh air, milk, and 
light work, he rapidly improved, and was well in a fortnight. He wets 
the bed much less, too, when well. But in four months, when employed 
as a message boy, he began to fancy he was dishonest ; got confused, 
crying badly, was depressed and nervous, and dreamed terrible dreams. 
He got well, and then relapsed. This tendency to recurrence, and re- 
lapse is characteristic of all the mental diseases in, and of all the neuroses 
of, puberty and adolescence. During his first attack he cried, screamed, 
moaned, and groaned, and was most restless. In two years from the 
first attack, after many relapses, he was sent to the asylum, and there, 
under proper diet and treatment, he got fat and cheerful, making a per- 
manent recovery. 

One gets a good idea of excited motor melancholia from a case of 
delirium tremens^ which, looked at from a symptomatological point of 
view, is a typical example of this disease. 

Trophic affections, such as boils, skin-itchiness, and irritations, causing 
the patients to pick their skin, tear out their hair, and bite their nails 
down to the quick, are particularly apt to occur in the marked forms of 
this excited melancholia, showing that the disturbances are profound, and 
extend markedly to the trophic functions of the brain. For the same 
reason, no doubt, some of the cases are intractably prolonged, and many 
incurable. In no variety of the disease do the muscular attitudes and 
expressions of mental pain get so fixed. I have a case now who has 
been melancholic for over twenty years, whose power of really feeling 
mental pain has gone, but who wrings her hands and groans, whose 
attitude is bent and despairing, and whose face in deep furrows expresses 
the intensest melancholy. This will come on quite suddenly, and go ofi* 
as suddenly, without any outward cause. If interrupted in the middle 
of one of these attacks of agitated psychalgia, and asked — "What's the 
matter. Miss Z. ? what are you crying about?" she will often smile, and 
say — "I don't know." "Were you unhappy ?" "No." Or if a glass 
of wine or a bit of cake is presented during the midst of the worst 
paroxysm, she will stop her groaning, take it, and smile. And, by 
assuming a sorrowful or a jovial tone of voice, one can make her groan 
or smile, and even sing a song. The melancholia has in time become 
muscular and automatic, without any real subjective feeling at all, and 
there is no memory of pain or pleasure, even for a minute. This inter- 
esting psychological condition is only seen when the convolutions are 
wasted or destroyed structurally. This condition is often seen in old 
persons. The brain is more profoundly disturbed in its functions in the 
excited than in any other form of melancholia, except that with epilep- 
tiform convulsions. 

Regarding the treatment of excited melancholia, it might at first sight 
appear that mechanical restraint of the motions of such cases, or at all 
events narcotic and temporarily paralyzing drugs, would be indicated to 



94 STATES OF MENTAL DEPRESSIOK. 

conserve the energy, and to save exhaustion. In former times, this plan 
of treatment was acted on habitually. In exceptional cases we do so 
still, but a closer study of the affection and the results of experience 
show us that evil results of the gravest kind are apt to arise by res- 
training the motions either mechanically or chemically. We see* that 
the motor effects are the natural outcome and outlet of morbid energy, 
generated in the brain ideo-motor centres. If they are restrained, the 
condition of the brain seems to suffer, the excitement to increase, and 
there is much greater risk of its exhausting and killing the patient, or 
the brain condition becoming incurable. So we let the patients walk, 
shout, and tumble, and we try and send the motor energy into normal 
directions by much hard walking in the open air, free scope, garden 
work, wheeling barrows, etc. 

I take the following case as a good example of the effects of such 
rational treatment in motor melancholia in what was a very severe 
disease, and of the possibility of treating such a case to a favorable ter- 
mination out of an asylum, during the whole of its course, when circum- 
stances are favorable : 

B. A., 8et. 60, a retired professional man, who had been in many cli- 
mates. Temperament w^as sanguine, diathesis nervous, .disposition very 
lively and social, habits active. He once before had a short attack of 
depression, and had recovered at home. The present attack began by 
simple depression and falling off in weight. He then passed through a 
hypochondriacal stage, complaining constantly of his bowels and diges- 
tion and liver. Those ideas increased until he had fixed visceral delu- 
sions. He had, as a matter of fact, prolapsus ani, but in imagination 
his bowels were all diseased, and his power of swallowing gone. His 
next stage was that of active motor excitement, showing constant rest- 
lessness by night and day — shouting, tearing out his hair, and picking 
his skin into holes. He recovered rather suddenly in about a year from 
the beginning of his illness, alter he had gained about twenty-eight pounds 
in weight. His treatment was throughout tonic and nutrient — quinine, 
the mineral acids, arsenic, iron, the bitter natural waters, and strychnine. 
He took as much as eleven tumblers of milk a day, and the only thing 
that, at one period of his case, made us not give up hope was that he 
was able to digest this, and that he gained weight, except during the 
most excited stage, which lasted for four months. He took tr. cannabis 
indicse and bromide of potassium for the excitement wdth marked benefit, 
and once, when he was very excited, but improving in strength, I had 
his occiput shaved, and a "large blister applied, also with benefit. He 
took no animal food during his illness. Warm baths, with cold to his 
head, produced quietude during his excitement. He had a first-rate 
male attendant and a devoted wife, and lodged in a suburban villa, with 
a large garden, where he stayed nearly all, day, driving and walking out 
when quiet. I have never treated a worse case of melancholia out of an 
asylum. 

Resistive (Obstinate) Melancholia. — In many cases of melan- 
cholia, obstinacy — an unreasoning, passive or active resistance to any- 
thing that other people want them to do — is the marked feature of this 
disease: to dressing, to undressing, to taking food, to going to bed, to 



STATES OF MENTAL DEPEESSION. 95 

getting up, to going out, to moving about, to micturating, etc. When 
this resistance is very extreme, as it sometimes is, it is a most difficult 
and very dangerous complication, from the difficulty of overcoming it 
and carrying out necessary treatment without hurting the patient. It is 
evident, too, that overcoming the resistance, and making the patient do 
things contrary to his will, is often attended with aggravation of his 
mental pain, causing excitement, and even violence.' As a general rule, 
he cannot say why he resists; but he does so persistently, doggedly, 
unreasonably, and in some cases with fierce violence. It is one of the 
symptoms that try most the patience of attendants and nurses, especially 
of the less gentle and reasonable sort. They cannot understand that it is 
a mere symptom of disease, and are apt to treat it as if it were sane obsti- 
nacy. Resistance is sometimes combined with active motor agitation, 
but most frequently it is passive obstinacy. Sometimes it is one feature 
of delusional insanity, and the direct result of the delusions present. 
One patient cannot pay for his clothes or food, and so will not wear the 
one or eat the other; another fancies that she is taken to execution, and 
so will not walk ; another is to be made a spectacle of, and so will not 
associate with other patients. Some have vague feelings of distress that 
the house is falling, and that the ground is unsteady, and so will not 
move. One most resistive woman I have now as a patient — B. B. — who 
will not do anything that is good for her. She will not put on her 
clothes or shoes, and says, in a vague, fearful way — "It's awful [this 
is a most common expression among certain melancholies]. I'm 
trampling myself down under the ground [and so she will not walk]. 
I'm in a hole to serve other people. I've neither meat nor drink [she 
had both before her, but in regard to those she had not the sweet sense 
of possession]. I dinna ken the beginning o't, and I dinna ken the 
end o't. I never thocht I was to be the key o' the earth. Everything's 
naething. I've come miles and miles. It's awfu'. I was forty when 
they changed me into this state. I dinna ken what age I am now. 
They've greased me a', and gin me oil [castor-oil], and done a' kinds 
o' things, and there's no a bit o' wit in me." She show^s that there is 
some delusional doubt in her mind as to her own personal identity, as to 
the ground on which she stands, as to time and space, and as to her own 
age; and she attributes all the bad feelings, etc., to what others have 
done to her. Her courage, sensibility, and muscular sense are perverted. 
Extreme obstinacy in cases of melancholia is usually the result of a com- 
plicated and deep delusional state such as this, in my experience, or to 
an insane stupidity, confusion of mind, and want of power of compre- 
hension or attention. There is an element of stupor in some of them, 
but usually of delusional stupor. One may not at the time be able to 
make out what the delusions are, but patients can, after recovery, usually 
tell what they were. In some of these cases, I am reminded of the re- 
sistance of a wild animal, or the behavior of certain savages, when first 
caught. Fear, the instinct of self-preservation, unreason, suspicion, and 
the instinct of freedom are all mixed up in the case. An evolutionist 
would have no difficulty in seeing in those phenomena a reversion to 
primitive instincts. I have often seen, as clinical accompaniments of 
such cases, a hot-feeling, perspiring skin and a })articulavly ofVensive, 



96 STATES OF MENTAL DEPEESSION. 

strongly smelling perspiration. Women have often greater mental con- 
fusion and obstinacy at the menstrual periods. Masturbation in both 
sexes often causes, aggravates, and accompanies this condition. They 
often admit afterwards that it was this habit which aggravated their 
confusion and obstinacy during the illness, but say that it was almost 
involuntary and automatic at the time. I have now a lady — B. ,C. — 
under my care, whose obstinacy is so extreme that it sometimes takes 
six attendants to dress her, yet, when the first article of clothing is put 
on, she will sometimes finish her dressing herself. A locked door makes 
her furious to open it, so we allow her to go where she likes, and almost 
do what she likes. She will stand in a passage for hours, evidently 
uncertain what to do, but any attempt to make her go one way will cer- 
tainly tend her to go the other with all her might. When opposed, she 
is fiercely resistant, attacking those about her most violently at times. 
Resistance to taking food in such cases is most common, and most pre- 
judicial to their recovery. They are unpersuadable, but sometimes when 
the first mouthful is forced into their mouths, they will then finish the 
meal. In other cases, if food is left near them in an out-of-the-way 
place, they will go and eat it by stealth, denying the fact afterwards. 
We often take advantage of this peculiarity to get them to take food. 
In some of those things they are exactly like a wild animal beginning 
to be tamed. 

This condition sometimes has more of confusion and stupidity than 
resistance or obstinacy, and when that is so, it is allied to melancholic 
stupor, of which I shall speak in another lecture. In fact, I have seen 
resistive melancholia a stage in a case passing into stupor, and then 
again a further stage in passing out of it towards recovery. 

The following was a prolonged case who recovered: B. D., set. 40. 
Married. Temperament bilious; diathesis nervous; disposition cheerful; 
habits active. ISTo children. First attack: duration eleven months. 
Assigned cause, depression from diarrhoea. Faint symptoms at first, 
suggesting epilepsy, but no true convulsion. Her father was epileptic, 
and a sister insane. She became depressed, and refused food, requiring 
the use of the stomach-tube for two months. Had delusion, e.g., that 
her husband was near her when he was far away. At first, she was 
treated in a private house, but her extreme obstinacy about eating, 
dressing, undressing, walking out, and coming home when out, implied 
more attendance at times than could be got in any private house. Was 
afterwards sent to an asylum. She there took her food, and slept well, 
but was ftill of delusions as to her husband and friends being in the insti- 
tution. She was very obstinate, dissatisfied and unsociable. 

On admission to Morningside Asylum, she was found to be laboring 
under melancholia, and to be in fair bodily health. Two months after 
admission, it is noted: "B. D. continues very restless and obstinate, and 
it is with difiiculty she can be got to do anything. She occasionally 
plays on the piano, but only does so to get a newspaper, which she 
seldom reads, but carries about with her, and will not give up again, 
believino; it contains messao;es from a friend. There is no active excite- 
ment or any other symptom — simply passive resistance to almost every- 
thino-. She constantly imas^ines that some relative of hers has come to 



STATES OF MENTAL DEPRESSION. 97 

see her, and, when out walking, will look into all sorts of improbable 
places for this person. She sleeps fairly at nights, but awakes very 
early in the morning, and is then very restless. Takes her food well ; 
gets tonics of all sorts." Continued, after eighteen months, as restless 
and obstinate as ever, and could not be got, without much trouble, to do 
any work. Slept badly, and Avas often restless at night. Took plenty 
of food, and kept in fair bodily health. But little doubt she was ad- 
dicted to masturbation, and w^as the worse for it. Looked sometimes 
very demented, and could not be got to do much work. Slept rather 
better. Took plenty of food. Prognosis seemed very doubtful. During 
the latter half of the second year, she was able to go out on pass on 
several occasions; and in the end of it, she was more settled and tidy 
in her ways, but still full of the delusions about people being present 
who were not, etc. 

In three years, after various trips to the seaside, and a tour in the 
Highlands, she had improved suflBciently to leave the asylum on a year's 
probation, going first to live in a family for a year, then taking a tour on 
the Continent, and finally being able to take up housekeeping for her- 
self, and getting rid of every trace of her mental disease, becoming very 
stout, healthy, and cheerful after about five years from the commence- 
ment of her attack. 

This case shows that treatment should be continued, and hope should 
not be given up for a long time in such a patient. 

The following is probably an incurable case : B. E., set. 46. Single. 
Education good; disposition cheerful; habits active and industrious. No 
known hereditary predisposition to insanity. First attack: duration, 
two months ; predisposing cause, change of life. She became depressed, 
and had melancholic delusions, e.g.^ that she had committed some crime, 
and must be punished; complained of headache, neuralgia, and uterine 
disorder. 

On admission, she had a look of stolid misery ; was evidently much 
depressed in spirits; was very obstinate and intractable; refused her 
food; was very taciturn, and showed a good deal of motor excitement. 
Her physical condition was poor, but there was no organic disease. 

From the beginning, there was the greatest difficulty in nourishing 
her, and for nearly ten months the nose-tube had to be used regularly. 
She resisted the operation of feeding in the most obstinate and dogged 
manner, the services of some half-dozen attendants being usually re- 
quired before a meal could be given. In the same manner, she resisted 
being dressed, undressed, taken out for exercise, going to the water- 
closet, or leaving it when there. Her resistance was not passive, but 
very active indeed; she would often strike and kick those who wished 
to make her go out, and she w^ould seize hold of anything near, and 
nothing but force would overcome her resistance. She behaved in a way 
trying to the patience of all concerned. About five months after ad- 
mission, she sustained a fracture of the right ulna — an accident evidently 
due to the force required to overcome her resistance. l^vo months 
after admission, a hiximatoma was observed in left ear, and was blistered 
with advantage. 

Her condition improved considerably for a few months, and the nose- 



98 STATES OF MENTAL DEPRESSION. 

tube was dispensed with. She gained in weight, did a little useful work, 
and at times talked rationally and cheerfully. This improvement, how- 
ever, did not persist, and eighteen months after admission, she was in 
the following very unsatisfactory condition : She is with great difficulty 
made to take her food. She is very irritable, obstinate, and wayward. 
She constantly desires to do what she ought not to do, and she will not 
do what she ought to do. She takes no intelligent or cheerful interest 
in anything; she sometimes uses very bad language; she complains 
peevishly when asked to do anything; then if told she must not do it, 
says she must; she is full of discontent and peevishness, but will do 
nothing herself or for herself, standing looking in a helpless way, as if 
tied to the spot, saying— ^' Don't let them put me out," or "bring me 
in," as the case may be. There are paralysis of volition, depression, 
inattention to the calls of nature, active resistance, and increased mental 
pain when her resistance is overcome by force. The prognosis is bad 
now after two years. Dirty habits developed eighteen months after the 
commencement of the attack. A hasmatoma in such a case is almost 
sufficient to warrant a verdict of incurability. 

Melancholia w^ith Epileptiform Attacks (Convulsive Melan- 
cholia). — In the excited form of melancholia, the motor movements are 
ideo-motor and volitional — that is, coordinated motions and indications 
of emotional depression without necessary loss of consciousness and 
memory. But in the form I am now to describe, the motor affection is 
a true convulsion with unconsciousness, occurring once or twice, seldom 
often, in the course of the attack ; and it differs in no way in some cases 
from an ordinary epileptic fit, and, in others, in no way from a. general 
paralytic epileptiform attack. It is a true epilepsy in Hughlings Jack- 
son's sense. This form of melancholia has not been described, though 
it is in my opinion the most serious variety of the disease. In it the 
whole of the functions of a brain convolution are affected — mental, 
motor, sensory, trophic, and vaso-motor. The mental depression is very 
intense, accompanied by muscular agitation and excitement, and usually 
by great obstinacy. There are usually much insensibility to pain and a 
tendency to skin irritations, so that the patients scratch themselves, and 
pick holes in their skin, or rub off their hair, or pull it out in patches. 
They are all prolonged, and practically incurable, for I have seen only 
two make even modified recoveries, and none of them have ever been 
able to work afterwards. It must be understood that I do not include 
in this variety convulsions of syphilitic or alcoholic origin. They 
are present in certain cases of those two kinds of insanity, but I shall 
refer to them under those headings. This variety of melancholia has a 
pretty distinct pathology too. I have never met with any case where, 
after death, some limited adhesion of the pia mater to the convolutions 
was not found, just as in general paralysis; but this was not found at 
the vertex, but on some of the basal convolutions. The structure of the 
convolutions is altered on microscopic examination, there being prolifera- 
tion of the nuclei of the neuroglia, especially seen around the arterioles 
and capillaries, with destruction of many of the nerve-cells. If my 
views in regard to the special pathological entity of general paralysis 
had not been so definite, I should have been tempted, in looking at the 



STATES OF MENTAL DEPKESSION. 99 

brain lesions in some of these convulsive cases, to have regarded the 
disease as an exceptional, localized, non-progressive^ general paralysis. 
But that would be pathological nonsense. One might as well talk of a 
non-fehrile typhoid fever. 

The convulsive attacks in these cases are very rare, only occurring 
once or twice or thrice in the course of many years. Sometimes the 
convulsion is prolonged, lasting for half an hour, with hours of uncon- 
sciousness, and a high temperature afterwards, as in general paralysis. 
In other cases, the fit seems like a sporadic attack of ordinary epilepsy. 
I have seen over a dozen of these cases, but of eight I have records, 
since I realized that this was a distinct clinical and pathological variety 
of melancholia — almost the only variety that can be correctly so de- 
scribed. Inasmuch as it is so, it ought properly to have come under the 
forms of mental disease in the clinical classification, but I think it more 
convenient and instructive to bring it in here. Of those eight cases, 
five had only one epileptiform attack ; two had two, and one had many. 
In six, they happened within three months of the beginning of the dis- 
eases ; in one, after three years, and in one only after twenty years. In 
three of them, the patients died within three years ; in five, they have 
lived — one for twenty-one, one for seven, two for six, and one for five 
years, and show no sign of dying.. They diifer entirely from ordinary 
epileptics, and from the cases with occasional epileptic fits that sometimes 
occur in advanced dementia, as the brain gets wasted. 

The following are examples of this form of melancholia : 

B. F., get. 61. Single. Temperament melancholic. Education good ; 
disposition cheerful, with periods of irritability; habits perfectly steady; 
teetotaller. One previous attack of melancholia. Hereditary predis- 
position to insanity; cause unknown. The attack began by a running 
down of bodily health generally. Duration of existing attack, three or 
four months. Has been depressed, and lately has had two epileptiform 
seizures, each lasting about five minutes. Attempted to cut his throat 
the day before admission. 

On admission was very depressed, and had many melancholy delusions. 
Said that he had lost all his money and was entirely ruined, that he was 
hundreds of pounds in debt, and that he can never pay what he owes. 
He was taciturn, obstinate and reticent, and displayed considerable 
impairment of memory. He was in feeble health, and had kidney and 
liver disorder. 

The prominent feature in this case is a curious unreasoning, automatic 
obstinacy. When dinner is announced, for example, no persuasion will 
get him to go down to the dining-room ; and when requested to go out to 
walk he simply will not go. He can give no reason for his refusal, and 
when force is used he resists with all his strength. In other respects he 
behaves in a very quiet and sedate manner. He is a very diligent 
reader, wakening up to activity when fresh newspapers or periodicals are 
brought in. He is usually little given to conversation, and he is slow to 
reply to any observation made to him. He is still very despondent, 
believing that he is ruined, and that he has not a penny of his own, but 
he has occasional outbursts of fun, and even pla^^s little practical jokes at 
times, and laughs at the result. Now and then he will talk as animatedly 



100 STATES OF MEXTAL DEPEESSIOX. 

and intelligently about things as ever he did in his life, and one could not 
then say there was anything wrong with him. Yet, in the midst of this, 
if his dinner is announced, or the time comes to go out to walk, he will 
become confused and obstinate, and will need to be taken out of the room 
by force, no amount or kind of persuasion at all availing. He has now 
been six years insane. He had no more epileptiform seizures, but does 
not improve or change mentally. 

This was a case of convulsive melancholia which became chronic and 
incurable, with muscular expressions of mental pain, but no real feeling. 
Enfeeblement of mind ; two epileptiform attacks — one twenty years before 
the other. 

B. H., aet. 36, when admitted labored under melancholia. Had been 
treated in the asylum ten years before, and had recovered. Insanity 
supposed to be due to too free use of stimulants. After eight years' 
residence she was discharged improved, but within three ^^ears she was 
brought back. She was greatly excited — crying, moaning, wringing her 
hands, and displaying generally a picture of the most intense misery, and 
had an epileptiform lit soon after admission. 

She has now been for twenty-one years in a condition of melancholia ; 
but with the lapse of time her feelings have become so blunted, and her 
intellectual faculties so dull, that while she still wears all the trappings 
and the suits of woe, her face drawn and furrowed, and in a fixed state 
muscularly of utter misery, her attitude that of utter dejection, and con- 
stantly wringing her hands and uttering a sound between a wail and 
a groan — she is inwardly, if not happy, at least free from real conscious 
remembered mental pain. For about two days in each week she is 
wonderfully bright and sensible. At other times she is very stupid and 
.helpless. At her best she is much enfeebled in mind, and is childish and 
forgetful. She rubs the hair off parts of her head incessantly, and often 
for hours she calls out — '^ Oh dear! oh dear ! " in the most dolefril tones. 
But when asked if she is unhappy, she smiles and says — ^' Oh, no; " and 
she will chat away in a pleasant, garrulous manner, and will sing a snatch 
of a song or play a tune on the piano, or beg for a bit of cake. She says 
she cannot help looking so miserable, and suggests that it may be due to 
her having a corn on her foot. She likes to be taken notice of and 
is orrateful for attentions, and often shows an amount of childish wonder 
and interest in little occurrences. She had a general epileptiform seizure 
in 1880, twenty-one years after the first, the second in the course of her 
disease. 

Orgaxic Melaxcholia (the Melaxcholia Accompaxyixg Gross 
Orgaxic Braix Disease). — I think the epileptiform variety of melan- 
cholia is analogous, from an etiological and pathological point of view, to 
that form, often only amounting to depression of spirits, wdiich very com- 
monly accompanies coarse organic disease of the brain, tumors, softenings, 
and wastings. It is usually in the first stages of those diseases that w^e 
have the mental depression, though in some cases it continues till death. 
In some of those cases I have seen the mental symptoms the very first to 
appear, long before the paralysis or even before great bodily weakness 
made its appearance. A paralysis of the sense of well-being and the 
enjoyment of life, a difiiculty in coming to decisions, a loss of mental 



STATES OF MENTAL DEPRESSION. 101 

energy, an intolerance of the usual work, if not an actual incapacity to 
do it well, a tendency to make slight mistakes in small things, a loss of 
memory, and a subacute mental pain, I have seen exist for two years 
before a man showed any diagnostic signs of brain ramollissement or 
tumor. The melancholia is usually of the simple type, seldom assuming 
the excited, delusional, or distinctly suicidal form. I have seen it of the 
hypochondriacal kind in a few cases. Organic melancholia commonly 
ends in organic dementia as the brain disease progresses, if the patient 
lives long enough. But the patients seldom need to be sent to lunatic 
asylums if they have money enough to pay for home nursing and 
attendance. 

The following is a typical case of organic melancholia, interesting 
from the bodily as well as from the mental point of view : 

B. J., set. 35. Melancholic temperament, nervous diathesis, cheerful 
disposition, and most industrious habits. An unusually intelligent man, 
who, after his business hours (and they were long and hard), read con- 
tinuously books on philosophy and science. There was no known 
heredity to mental or brain disease. He had mental worry and business 
disappointment, with a weariness, lassitude, and loss of energy. The 
disease began by his being forgetful of things. This he was conscious of, 
and it worried and depressed him, and from some expressions he used 
his friends feared suicide. He had at the same time headaches, then he 
felt bad smells where none existed (a grave symptom always), then he 
began to take short unconscious attacks, without convulsion or falling 
down, sometimes several times a day. 

When I saw him first, eight months after the symptoms had begun, he 
was depressed, but without any intellectual delusion. He could not read 
or apply himself to anything ; his memory was bad ; he had terrible 
heada( hes, and a feeling of a band round his head ; his head was not 
pained by tapping with the finger ; his right face, arm, hand, and leg 
were weaker than the left, and he had a peculiar slow mode of speech, a 
difiiculty in remembering words, and a tendency to use wrong words 
having the same general sound to those he wished to use. Sexual desire 
and capacity had ceased for six months. He was constantly sleepy and 
yawning, and would go to sleep as he sat and talked to one ; in fact, all 
the time he seemed like a man half asleep (a grave symptom too). He 
had a perpetual weariness. Face very heavy and expressionless. When 
very bad one day, and he wanted to say that he never had a foul tongue, 
he said — "I never was like some folks that show that they have a strong 
color on the tone — on the tongue." His bowels were excessively costive. 
My diagnosis was serious brain disease aifecting the convolutions, but 
chiefly confined to the left side. I thought it might be softening or 
tumor. In case it might be of syphilitic origin, and also because I had 
found this treatment gave relief in cases of this kind of non-specific 
origin, I put him on large doses of the bromide and iodide of potassium, 
witli one-twelfth grain doses of corrosive sublimate. I also blistered* his 
head severely behind. Tliis treatment undoubtedly relieved the intensity 
of the pain, and stopped the unconscious epile})tiform attacks. His tem- 
perature at this stage was subnormal, seldom exceeding 97°. In three 
weeks after I saw him he had got distinctly worse. He walked worse. 



102 STATES OF MENTAL DEPRESSION. 

staggered, and ^vould fall backwards and to the right if left alone. He 
spoke worse, and wrote worse, e. g., when I asked him to write "my 
hat," which was before him, he wrote slowly '-'-mliate.'' His temperature 
was 100° in the evening. He died suddenly next morning. 

On fost-mortem examination, I found on removing the dura mater 
that the convolutions bulged, and were flattened especially on left side. 
The whole of the middle lobe of left side felt baggy and fluid on pressure. 
On section the lateral ventricle of that side was enlarged, and almost all 
the white substance of that lobe was gelatinous, stringy, with a pale 
straw-colored fluid oozing from it. It was, in some respects, unlike 
any case of brain softening I had ever seen. The gray matter forming 
the gyri of the middle lobe was pale and soft, but not difiluent or gela- 
tinous. The pia mater stripped off" it very readily. The corpus striatum 
and optic thalamus of that side were softened to some extent. I could 
find no embolism or thrombosis of any of the arteries to account for the 
softening. The anterior and posterior lobes were pale, and wanting in 
consistence, but not gelatinous. Broca's convolution was not greatly 
afiected. The right hemisphere was pale and soft, especially the whole of 
the central white substance, but was not gelatinous like the left. In the 
pons just under the floor of the fourth ventricle, was a small recent 
apoplexy, the size of a split-pea. 

None of the current vascular or embolic theories explains such a case 
of brain softening. I think such a disease is the result of morbid trophic 
changes of purely nervous origin, and independent of the blood supply. 
Some of the modern authorities would apparently deny to the nerve tissue 
an inherent power to waste or disintegrate, or to become diseased indepen- 
dently of the blood supply or the packing tissue changes. I believe in 
no such theory. Over-mental work does not directly affect the blood- 
vessels, yet it causes brain changes of the most serious kinds. Even 
when vascular changes are found, I believe them to be secondary in great 
measure to the alterations of nervous structure. The bloodvessels and 
the neuroglia are, after all, the servants of the brain tissue proper, and 
this has not been kept sufficiently in mind in recent nerve pathology. 

On the vascular starvation theory of brain necrosis it has been always 
assumed that some mechanical obstruction of a vessel by embolism or 
thrombosis is required. I have seen most of a hemisphere softened and 
bloodless, with every vessel ftiHy patent. There had evidently been a 
spasmodic closure of the vessels, a true vaso-motor spasm of a prolonged 
and complete kind, starving one hemisphere of blood and killing the 
patient. I believe that frequently happens, and is the cause of soften- 
ings, epilepsies, spasms, and mental affections in different cases. 

Such a case is a type of dozens, more or less like it, that I have seen 
in consultation, and that most practitioners in medicine have seen. It is 
most instructive, as showing that the mental functions of the brain were 
first to show, by their disorder, that the organ was beginning to be dis- 
eased, and that mental depression was one marked early symptom of the 
incipient trophic changes in the tissues. They confirm strongly m}^ idea 
that mental depression, jper se, is simply the functional expression of con- 
volutional malnutrition. 



STATES OF MENTAL DEPKESSION. 103 

The following is an interesting case in a more acute form, with chiefly 
convolutional disease, and no such extensive ramollissement as the last: 

B. K., aet. 39. Single. Clerk. Disposition very cheerful, frank, 
and social ; habits quiet and industrious ; doubtfully temperate ; no pre- 
vious attack ; sister insane. Has had indigestion for years, and has led 
a very sedentary life. Two years ago a change in his behavior was first 
noticed, and for the last six weeks he has been very depressed and unfit 
for w^ork. Thought that he was a wicked man, that he had ruined his 
friends, and that he was going to die. Has been sleepless ; has refused 
food ; has fallen off greatly in weight ; and has complained of constipa- 
tion. 

On admission is in a state of great depression ; says he cannot live 
over twenty-four hours, and that he is utterly ruined in soul and body, 
and one of the greatest sinners in existence. Is restless, unsettled, and 
comfortless ; cannot sit still for a moment. Complains of obstinate con- 
stipation ; is unsteady in his walk ; articulation is spasmodic and falter- 
ing ; left pupil is larger than right ; left side of face is flatter than 
right ; there are occasional twitches in the facial muscles ; reflexes im- 
paired. 

Slept v/ell first night, but little afterwards. Took plenty of food. 
Bowels cleared out with magnes. sulph. and an enema. Two days after 
admission he had a severe general convulsive seizure, with loss of con- 
sciousness. Consciousness was regained in a few minutes, and shortly 
afterwards he became considerably excited, talking in a confused, excitedly 
delusional way about "Her Majesty," "her message," "the Queen 
coming," "the soldiers," etc. Was sent out for an hour's walk; was 
then given a draught of chloral and bromide of potassium, and was 
put in bed in a dark room. Slept well for two and a half hours, and 
since then has been quiet, and depressed as on admission. This is a 
mode of cutting short the mental excitement after an epileptic attack I 
often employ. After this was more taciturn and confused, and the defect 
of articulation more marked. Is very nervous, tremulous, stupid, and 
unsteady, and displays general muscular twitching, best marked in right 
side of face. In a fortnight after admission had retention of urine, and 
required use of catheter. Became much weaker ; trembled greatly ; 
limbs jerked ; face twitched ; only rarely could be got to utter a few 
words spasmodically. 

Was ordered potass, iodid. gr. x and potass, bromid. gr. xxv thrice 
daily. After this tremors less marked ; looked very exhausted ; slept 
very little ; refused food ; became more obstinate and intractable ; rarely 
spoke ; had an expression of disgust and hopelessness ; was fed with dif- 
ficulty ; catheter used twice daily. Refused food ; very slow and stift' in 
his movements at times ; confusedly excited. On the twenty -fourth day 
after admission, got suddenly worse ; expression haggard ; fiice pale. In 
the evening, when walking to his bedroom, he suddenly collapsed, and 
expired quietly. 

Autopsy — Head. — Skull-cap dense; dura mater thick; pin mater 
thick, tough, and very much injected, and was adherent to gray matter 
over posterior part of orbital surface of frontal lobes, llemispliores on 
section extremely injected, especially the right. Gray matter thin licre 



104 STATES OF MENTAL DEPEESSION. 

and there. In left optic thalamus two distinct softened spots. Basal 
ganglia, pons, medulla, and cord very hypersemic. Lining membrane of 
lateral and fourth ventricles thick and finely granular. 

On microscopic examination of sections of the brain, there were found 
innumerable microscopic apoplexies into gray and white substance, great 
dilatation of the arteries and capillaries, and a universal proliferation of 
the nuclei of the neuroglia and connective tissue generally. Along the 
lines of the smaller vessels there appeared, in stained sections, vast col- 
lections of nuclei clusterinor round the vessels, extendino^ far into the 
brain tissue, and, of course, far outside the perivascular canals (see Plate 
VII., Fig. 4). 

Chest. — Aorta atheromatous. Lungs congested and very oedematous. 
Other organs healthy. 

Suicidal and Homicidal Melancholia. — The question of the pa- 
tient being suicidal should never in any case of melancholia be left un- 
considered, and the risk of his becoming suicidal should never in any 
case be left unprovided for. No tendency to suicide exists at all in many 
melancholies from beginning to end of their disease, but it does exist in 
some form or other, in wish, intention, or act in four out of every five of 
all the cases, and we can never tell when it is to develop in any patient. 
The intention and the act may come on suddenly, by suggestion from 
without or within, or by the sight of opportunity or means of self-de- 
struction. When a man takes away his own life, or even when a serious 
attempt is made, it is so distressing to every one connected with the pa- 
tient, so hurtful to his prospects, and so damaging to the reputation and 
foresight of the doctor in charge, and so in the teeth of the radical 
medical principle to obviate the tendency to death, that no pains should 
be spared to guard against its occurrence. While it prevails so com- 
monly in all forms of melancholia, there is a variety of this disease 
which is specially characterized by the suicidal intent and impulse, and 
of all the forms of mental depression this is one of the most striking and 
most important. When the love of life, that primary and strongest in- 
stinct, not only in man, but in all the animal kingdom, through which 
continuous acts of self-preservation of the individual life of every living 
thing take place, when that is lost, and not only lost but reversed, so 
that a man craves to die as strongly as he ever craved to live, we have 
then the greatest change in the instinctive and afiective faculties of man 
that is possible, and have reached the acme of all states of mental de- 
pression. Suicide in some cases is a desperate impulse, in others an in- 
satiable hunger, in others a fixed resolution to be calmly and deliberately 
carried out, and in others a frantic attempt to escape imaginary calamities 
or tortures. 

The determination to commit suicide is, in some cases, one come to in 
the calmest and most reasoning way. A patient says — "I'm utterly 
miserable; I am not going to recover. Why should I live in torture?" 
and so determines to end his life. Such cases are nearest in character 
to the suicides among sane persons which Morselli's statistics^ show are 
increasing nearly in all the civilized countries. Next to this mode of 

' Suicide, Henry Morselli. 



STATES OF MENTAL DEPRESSION. 105 

arriving at the suicidal purpose, in my experience, come the attempts to 
commit suicide from the motive, illogical as it seems, to escape imaginary 
torture or persecution. This, too, causes one of the most common mis- 
takes made in not taking precautions against it. A man is desperately 
afraid he is going to be hanged for some imaginary crime, and his friends 
think it would be absurd to have any one watched against taking away 
his own life who seems so morbidly fearful that some one else is going to 
do it for him. But this is one of the most dangerous class of cases. 
The psychological condition of such a person, when analyzed, is found to 
be this : that there coexist a paralysis of the life-love, a suicidal longing, 
with delusions of persecution or torture side by side. They are mental 
symptoms of the same brain disorder. A very suicidal lady — B. K. — 
in this state wrote a friend: "If my soul and body could both die, 
this would be my salvation ; but no, this will not be. God ! how 
dreadful seems my case. Sadness, terror, tortures intolerable will be my 
portion." In other cases, there is a direct delusion or hallucination 
leading to the act of self-destruction. The patient thinks himself too 
bad to live; that he pollutes the earth; is a source of misery to his re- 
lations ; that he must sacriiice himself to save others ; or he hears voices 
— of God, of the devil, of friends and enemies, dead and alive — saying 
to him: "Kill yourself;" "Cut your throat;" or there is a longing for 
death simply, so intense as to overpower all other motives and considera- 
tions, without any delusion — a death-love that acts as a fascination. Then 
there are cases where there is no love of death at all, but rather a fear 
of it. Yet an ungovernable, morbid impulse impels the patient to 
commit suicide against his will, and contrary to any resolution he is able 
to form. Lastly, there is the epileptic suicidal impulse while the patient 
is in a state of false consciousness, with no memory of the act afterwards 
at all. But the last two I shall treat of under the heading of impulsive 
insanity. Naturally, it follows, such being the immediate motives to 
suicide, the act is carried out or attempted in a great variety of ways. 
Sometimes it is sudden, the desire to do it arising in a moment, w^ithout 
warning; in other cases, it is led up to by the clinical history of the 
case very gradually ; in other cases, most elaborate preparations have 
been made to accomplish it. Twice in America — one, I think, in im'ta- 
tion of the other— men have constructed an elaborate apparatus, taking 
months to make, by which the contriver gave himself chloroform first, 
and, when unconscious, an axe was let loose, and chopped off his head. 
In other cases, much cunning and mendacity are used to throw friends 
off their guard, so as to enable patients to effect their purpose. As a 
general rule, the more it is talked of by a patient, the less danger of its 
being carried out; but to this there are exceptions. In most really 
serious cases, this is less talked of by the patient than any other symptom 
of melancholia. The most absurd precautions are sometimes taken in 
doing the act. Very often patients take off some of their clothes when 
going to cut their throats. I liad a patient once who, in his own 
house, arranged himself most carefully over the scat of his water-closet 
before he opened a vein in his arm with a penknife. 

Various things determine the real amount of risk — the intensity of 
the disease; the amount of cunsciousness and volition left; the tempera- 



106 STATES OF MENTAL DEPRESSION. 

merit of the patient; the means available; the suggestions offered in the 
shape of opportunity; that is, the sight of knives, ropes, water, open 
windows, poison, ' which, in certain cases, can rouse into activity a till 
then dormant suicidal desire; and, above all, the natural courage and 
resolution of the patient. The effect of the last element is overwhelm- 
ingly proved by the fact that only one woman commits suicide for every 
three or four men in all countries, the suicidal desire, I find, being more 
frequent in -women than men. There are some hypochondriacal and 
simple melancholies who are always talking of suicide, and who never 
go further than talk and ostentatious preparation. I have referred to 
the hypochondriac (A. L., p. 69) who tried to hang himself by pulling 
himself up a flagstaff with one end of the rope around his neck and the 
other in his hand. I knew a patient alarm his friends by drinking a 
liniment which he knew to contain only a little tinct. saponis ; another 
who w^ent and bought no less than thirty yards of rope, hinting his fell 
purpose to the shopman; another who was always tying thread and gar- 
ters around his neck, just tight enough to make a mark ; and many who 
tried to end their lives by holding their breaths. In some suicidal cases, 
there are curious automatic suicidal movements quite unconsciously done. 
I have always many patients who would, at times, put their hands to 
their throats, and compress them slightly. Some patients regularly 
"work at their throats" in that way. I have seen continued in a patient, 
as an automatic muscular habit, the mere organic memory of a melan- 
cholic suicidal state which had then passed away, the patient being at 
the time cheerful and convalescent. So I have seen patients gently 
strike their heads against walls, and play with dinner knives, as if to end 
themselves, long after any real suicidal desire had gone. 

Regarding the modes of committing suicide, there are eight most 
common — drowning, hanging, starvation, wounds, fire-arms, poisoning, 
precipitation from a height, and asphyxia. But other and rarer methods 
are as diversified and original as human imaD;ination can conceive. 

Some things seem to go contrary to the radical instincts of human 
nature, e.g., going into boiling water, or swallowing it, or putting a hot 
coal into the mouth, and attempting to swallow it. But I have seen one 
example of each of all these modes of attempted self-destruction. "Each 
country," says Morselli, "has certainly its particular predilections." He 
says, too: "In the choice of the means of death, man is generally guided 
by two motives — the certainty of the event and the absence or shortness 
of suffering." I disagree entirely with this. I think he is guided by 
the readiness and the simplicity of the means at hand; by the absence 
of ideas connected with them repugnant to the instincts of human nature; 
by his natural temperament, and by the suicidal traditions of his country, 
or race, or profession, In China and Japan the means used are entirely 
different from those in Europe. But one fact is of great practical and 
prophylactic importance. The same patient very often sticks to one 
means of suicide. A man who wants to cut his throat or drown him- 
self will frequently pass unattempted innumerable opportunities of 
hauD-ino;. Even the vanities, follies, and eccentricities of human nature 
come out strongly in the modes of committing suicide. I knew a man 
who was very particular about his linen, and could not bear the idea of 



STATES OF MENTAL DEPRESSION. - 107 

cutting his throat, because it would soil his shirt-front, and people might 
say he had not had on a clean shirt 'that day, while he was most anxious 
to get poison. 

Patients frequently starve, or attempt to starve themselves, in order to 
terminate their lives; yet food is by no means always refused in insanity 
with that direct object. It is refused from patients havirig delusions about 
its containing poison ; as to their not being able to pay for it ; as to their 
bowels being costive or obstructed; as to their having no stomach; that 
they would burst if any food is taken; they hear voices telling them not 
to take it ; or there is simply a paralysis of the appetite for food, with a re- 
versal of that appetite in the form of an intense dislike to it. It may be 
convenient here to refer to the best means of forcible feeding. If per- 
suasion, a little starvation, in strong cases, and fresh air and exercise do 
not make them take it, patients will frequently masticate and swallow when 
it is put into their mouths. From very long experience, I say that a liquid 
custard of new milk, cream, and three or four eggs, flavored with a dash 
of nutmeg or sherry, is the very best and handiest form of liquid diet at 
first, and for a time at least. If feeding has to be long continued, the 
best way is to have a big mortar, and pound into a liquid form, with 
beef tea, the ordinary diet. Beef, mutton, fowl, fish, and vegetables of 
all kinds can in this way be liquefied. Always add one-fourth of a pound 
of sugar to each meal, and feed twice or thrice a day. If the patient 
will not swallow, the simplest and most available of all apparatus i& 
about six inches of India-rubber tubing, from a baby's feeding bottle, 
that can be got at any chemist's, and a small funnel of any sort. With 
this latter inserted into one end of the tube, and the other end well 
oiled, and passed along the floor of the nares to the pharynx, we can 
pour down the custard in tablespoonfuls, and the patient must swallow 
it. But an obstinate patient soon gets into the trick of expiring just as 
the fluid is entering the pharynx, and so blowing it out of his mouth. 
There are now made French red rubber elastic tubes, like longer, stouter 
catheters, which can be passed down into the oesophagus, and so over- 
come this difiiculty. This implies no forcible opening of the jaws, and 
will succeed in five-sixths of the patients. But in case this method 
fails, we must use the French rubber tubes of large size passed into the 
stomach by the mouth, which must be first opened by a suitable instru- 
ment (to be got from all good instrument makers). This mouth-opener 
should always be tightly wrapped around at the points with strong tape 
to protect the teeth. Never bring the steel in contact with the teeth. 
If there is very great difiiculty in opening the mouth, two openers, one 
put in at each side of the mouth, and both screwed up at once, obviate 
all difiiculty. For forcible feeding have plenty of assistance. Use a 
large stomach-pump, or a funnel at the end of the tube held above the 
patient's head, to pass the liquid nourishment into the stomach. Take 
care the patient does not get up and tickle the throat, and vomit the 
food after the meal. With good tubes and instruments, and plenty oi" 
assistance, the patient being placed on a bed or sofa, with his head raised, 
he can be fed quickly and easily. I now never have any ditliculty. I 
must say, however, that I liave met with one patient where I could not 



108 STATES OF MENTAL DEPRESSION. 

pass the French soft rubber tube, and where I had to use the old stiffer 
gum-elastic tube, so that it is well to have one on hand. 

My experience is that the greatest danger of suicide is near the com- 
mencement of the attack of melancholia. The impulse is then strongest. 
Like any other disease, its intensity gets spent after a time. So with 
refusal of food. It is generally most troublesome at the beginning. ' 

As showinoj the contradictory feelings in a mildly suicidal case, this is 
the letter of one (B. K.): "I wish you would come to see me. I never 
sleep at all now. I am very ill, and I am in despair about my soul's 
salvation. I wish I had an opportunity for suicide. I hope to see you 
soon. I am very much afraid of hell. I am getting worse, and I see 
no chance of getting well. I sometimes wonder how much money I have 
lost. I am afraid of losing money by being fined for blasphemous 
writings or whisperings [which he indulged in often]. I wish I was 
dead. The keepers have been very kind to me. I hope to live with 
you soon. If you lived in Edinburgh I would be very glad to see you. 
I am afraid of dying suddenly. I would be happier with you. I hope 
to be better when you come. Write soon. I am afraid of hell very 
much. Is your health good ? Keep your money safe beyond my reach. 
Yours affectionately." 

It is most important to estimate the degree of intensity of the suicidal 
feeling. Is it quite obviously over-mastering ? Is the power of atten- 
tion greatly impaired ? Are the natural habits or propensities changed ? 
the likings and antipathies interfered with or reversed ? Is the sense of 
the ludicrous gone ? But it must be remembered that the sense of the 
ludicrous may not be gone, and yet a serious suicidal intent may be 
present. I have seen outbursts of gayety in a suicidal melancholic. Is 
the capacity for ordinary enjoyment gone ? Are the delusions wholly 
believed in or only partially so ? Is the suicidal feeling much spoken 
about or not ? 

The following is a record of one of the most persistently and strongly 
suicidal cases I ever had under my care : 

B. L., a professional man, aged 25, of melancholic temperament ; 
nervous and reserved but kindly disposition ; temperate and industrious 
habits ; had been a hard student. A cousin of his mother and one of his 
great maternal great aunts were insane. Comes of a professional family. 
There was no exciting cause for his illness. Nine months ago he got 
dull and sleepless. He first thought he did not do his professional work 
well ; then, by a natural transition, as his disease acquired more power, 
that he had committed some crime and ought to die, and that his soul was 
lost. He took a poisonous dose of belladonna with suicidal intent before 
admission. He had fallen off in bodily strength and flesh. On admission 
he was perfectly coherent, and his memory good, but much depressed, 
with no interest in anything, and with the delusions above mentioned. 
In spite of treatment, which consisted of nutritious food and tonics, and 
attempts to get him emploj^ed and his attention aroused to healthy 
objects of interest, he got steadily worse. His pulse was weak, his tem- 
perature low, his muscles flabby, his complexion pale, and his bowels 
costive. He walked rapidly about, and could not sit down long or settle 
himself He said he was troubled much with seminal emissions, and 



STATES OF MENTAL DEPRESSION. 109 

this seemed to depress him further. He had a dislike of animal food. 
He made innumerable attempts at suicide in quiet, reasoning, deliberate 
ways. He put his fingers down his throat ; he swallowed berries of the 
Arbor vitce picked in the grounds ; he swallowed eighty-two small stones 
gathered in the gravel walks (weighing twenty-four ounces), and passed 
them without doing him any harm ; he tried to push a nail, picked up 
and secreted for the purpose, into his heart ; he seized a bottle of whiskey 
one day and' drank part of it. Even when intoxicated with this he was 
miserable, and his dreams, he said, were only a little less depressing than 
his waking thoughts, which were always that he was wronging everyone 
by allowing himself to live, and that he ought to take away his life and 
so end his misery and lessen his punishment in the other world. He 
refused his food for a time, and had to be fed with the stomach-pump. 
I was singularly unfortunate in the attendants I placed in charge of him, 
for they got most careless, and one or two I dismissed on his account. 
He was so quiet and reasonable and nice a man, and tried so successfully 
to throw them off their guard, and his attempts were so carefully planned 
that, no doubt, a man unacquainted with disease fx^om the physician's 
point of view was most apt to be thrown off his guard. An attendant 
will be most alert for a few weeks, but when it comes to months, and 
when the man he has to watch seems as reasonable as he is himself, and 
is quiet, it is almost impossible to get one who will not give such a man a 
chance some time. The whole mental energy of B. L. was employed all 
the time in scheming suicide. And when such a man is a doctor, it simply 
is a question of how long he will take to get a chance. He drank some 
turpentine, used for polishing, once, and nearly died. He was weak and 
threatened with bed-sores, and his attendant got a solution of guttapercha 
in chloroform to paint over his skin. B. L. seized the bottle and drank 
a quantity of it. We had to use artificial respiration by Sylvester's 
method and the interrupted current for fourteen and one-half hours, 
when, to our surprise aud delight, he began to breathe, and told us to "go 
to hell."^ That case taught me many lessons, practical and medical. I 
have never trusted one attendant continuously on duty in such a case 
since. I have never believed anyone to be dead since, merely because he 
could not breathe and his pulse could not be felt. Six months after 
admission poor B. L. died of slow exhaustion. Food would not nourish 
him ; stimulants would not rouse him. He determined to die, and 
accomplished his object by the strength of his volition. 

The following was a case of acute suicidal melancholia coming on 
suddenly, caused by prolonged affective strain, anxiety, and want of 
sleep, with intense suicidal feeling, and many attempts : no sleep ; 
exhaustion, and death in a fortnight : 

B. M., aet. ^^^ a man of a melancholic temperament, nervous diathesis, 
rather over-sensitive disposition, great intellectual power, and good edu- 
cation. For months he had had too little sleep, and very great domestic 
anxiety. This did not seem to tell on him till a sudden outbreak of 
intense melancholia, with suicidal feeling, came on him without any out- 

^ A full account of this case was j)uMisluHl hy Dr. J. J. Hrown. then one oi my 
assistants, in the Edinburo-h Medical Joui-nalfor November, 1874. 



110 STATES OF MENTAL DEPEESSION. 

ward warning. But, no doubt, he was a man with immense power 
of inhibition, who had the capacity to work his brain up to the point of 
complete exhaustion, and also conceal from others any evidence that he 
was doing so. This phenomenon is very often seen in women nursing 
those dear to them, or "keeping up" themselves and others under loss or 
calamity. They look cheery up to the last, and do their work, but they 
break down suddenly, and sometimes incurably. He asked one morning 
that his razors should be put away, and within an hour or two he had 
entirely lost his power of self-control, gave expression to the intensest 
melancholic delusions — that he was too wicked to live, and could not 
live ; that he was lost, ruined, etc. When placed in charge of attendants, 
as he was at once, he made many and desperate attempts at suicide, so 
that he could not be left for a moment. He could not be roused to 
attend to anything, he was restless, moaned, and never expressed any 
interest again in his Avife, or family, or concerns. There was a sudden 
paralysis of his love of life, of wife, and of children — of his interest in 
anything but his delusions. His tongue was furred and tremulous, his 
facial expression that of despair, his pulse feeble, his temperature 100°, 
his appetite gone, his bowels costive, and his skin ill-smelling. He never 
seemed to rally, and died within a fortnight of the acute brain disease, 
though he had every care and attention, plenty of food and stimulants 
and nursing. The cells of the gray matter of his convolutions were 
found extensively degenerated. 

Feequexcy of the Suicidal Impulse. — The prevalence of the 
suicidal tendency in melancholia can only be correctly brought out 
by taking large numbers of cases. I have taken the last seven hundred 
and twenty-nine cases of melancholia under treatment. These were from 
all classes of society, and this is a valuable point, in the Morningside 
Asylum statistics, as compared with those in an asylum for paupers only. 
The disease in all those patients was decided and marked, otherwise the 
patients would not have been sent to the asylum. All the very mild 
cases would be kept at home, and many of the decided cases too among 
the richer classes. In regard to melancholies treated at home, I have no 
means of ascertaining the prevalence of the suicidal feeling, and it must 
be kept in mind that many of my patients are sent to the asylum on 
account of their suicidal tendencies chiefly, and, but for these, would 
have been at home. It may fairly be regarded, then, as far more common 
among asylum melancholies than among those laboring under the disease 
out of asylums. Among those seven hundred and twenty-nine there 
were two hundred and eighty-three, or about two-fifths (thirty-nine per 
cent.), who had actually attempted to commit suicide. In many cases, no 
doubt, the attempts could scarcely be regarded as being very serious. 
In addition to this number there were three hundred and one cases, or 
two-fifths more, that had spoken of suicide, or given some indication that 
it had been in their minds. That makes five hundred and eighty -four out 
of seven hundred and twenty-nine melancholies, or four out of five of the 
whole, that were more or less suicidal. No wonder, therefore, that the loss 
or perversion of the instinct of the love of life is regarded as one of the 
chief symptoms of melancholia. I am quite sure, however, from what I 
know of the disease, that the actual risk of suicide being seriously 



STATES OF MENTAL DEPRESSION. Ill 

attempted or accomplished is much less than those figures would seem to 
show. The really typically suicidal variety of the disease, in which the 
desire to die is very intense and is the chief symptom present, the cases 
of which would certainly put an end to their lives if they had the oppor- 
tunity, is not so frequent. As near as I can estimate, one melancholic in 
twenty only is of this kind. 

There is one peculiarity about the suicidal feeling which it is well 
to keep in mind, and that is its liability to return suddenly or to be 
called up by the sight of means of self-destruction. I had a patient who 
was all right so long as he did not see a knife. That set up the demon in 
him at once. 

The homicidal feeling is much rarer in melancholia than the suicidal. 
They frequently coexist ; but in some few cases the homicidal feeling 
exists alone without the other. At the beginning of acute alcoholism 
we all know how common are those tragedies that shock us in our news- 
papers, men killing their wives and children, and then themselves. We 
shall also see that in puerperal insanity there is a strong tendency in 
many of the cases towards child-murder ; but, apart from those two 
special forms, only a few ordinary melancholies have homicidal feelings, 
of which the following case is an example, with hallucinations of hearing 
voices telling her how to commit suicide, and a homicidal attempt : 

B. P., aet. 30. Widow ; of a sanguine temperament ; frank and 
cheerful disposition ; temperate and industrious habits. First attack. 
Cause : annoyance at some legal proceedings three days ago. Became 
depressed and very restless, sleepless, and her appetite disappeared. She 
began to think her children were murdered, and that people were going 
to kill her. Whenever you see such delusions, look out to prevent sui- 
cide. It is a most common accompaniment. She had hallucinations — 
hearing voices telling her to commit suicide, which she attempted by 
drowning. Had been taken to the police-office on emergency, and was 
at once sent to the asylum. On admission she suffered from intense 
mental depression, crying, saying she had been drugged at the police- 
office, and by a servant. She said that a chimney-can turning with the 
wind, said to her: "Drown yourself, prepare yourself, drown yourself." 
She was excited and restless in manner, and jerky in her muscles. She 
could answer questions, and her memory was not gone. Her expression 
was depressed, suspicious, and alarmed ; her skin muddy and spotted ; 
pupils unequal ; eyes glistening ; was fat and muscular ; tongue furred ; 
bowels constipated ; appetite gone ; refused food absolutely ; was men- 
struating. Temperature, 100.1° ; pulse, 108. Was restless the first 
night, which she spent in a dormitory with the attendant, who twice 
during the night sent a report about her to the assistant physician. At 
5.30 A.M. next morning she made a most severe homicidal attack on the 
attendant, nearly strangling her. Her motive for this was not expressed. 
It might have been a pure homicidal impulse, or it might have been, and 
I tliink it Avas, from the delusion that the attendant was going to murder 
her. The assistant physician after this, finding that it was to be a con- 
tinuous struggle with the attendants, had her placed in a bedroom alone, 
with the shutters locked and everything made secure, as he thought, with 
an attendant to look in every ten minutes. He reported this to nie, and 



112 STATES OF MEXTAL DEPRESSIOX. 

I approved of the mode of treatment. Slie refused breakfast, breaking 
her dishes, and fighting with the attendants. She was seen at 12.80 or 
12.35 by the attendant lying quietly in bed, but at 12.45 it was found that 
she had hanged herself to the shutter bar, which had not been properly 
constructed, with a piece of her sheet, her feet being on the ground. The 
efforts at artificial respiration were unavailing. 

This is an example of acute suicidal and homicidal melancholia, the 
worst of all cases to manage. If you keep attendants with such a pa- 
tient, there is a struggle and much danger to both ; if you place him 
alone, there is always some risk of suicide. What I do now is to put on 
such a patient clothing of strong untearable linen, to give for bedding 
blankets quilted in soft untearable canvas, and put him in a padded room, 
with an attendant outside the door. It will be seen, from the tempera- 
ture and whole conditions that such a condition has many of the charac- 
ters of an acute disease. Such acute symptoms do not usually last long. 
If we can tide over the first week or two, we expect all the symptoms to 
abate after that. The hallucinations of hearing in such a case may dis- 
appear, and are not of such grave import in prognosis as in less acute 
cases. 

The homicidal impulse in a slighter form is more common. I have 
now two ladies under my care — B. Q. and B. R. — who kick, and punch, 
and strike their attendants and fellow -patients, declaring they cannot 
help it. One of them. B. Q., has the suicidal impulse too. and strikes 
her head and breast. She cries to be put in a strait waistcoat, to prevent 
this. I tried this once, but it had no good effect, and it gave her no 
more sense of security, and she did not sleep any better. In the other 
case, B. R., she only has the homicidal feeling in the morning. In the 
evening she is quite lively, dancing and playing on the piano, and smiling. 
The homicidal feeling is undoubtedly the human instinct of slaughter 
and destruction in a morbid form possessed by all men. I had a case in 
which it seemed to result from an excessive production of motor energy 
in the nerve centres, for any mode of expending this by tearing his 
clothes, digging in the garden, fighting, or gymnastics would relieve his 
homicidal feeling for the time. I take it that such a case is very analo- 
gous to the physiological instinct of breaking things in children. Many 
of the excited melancholies tear and break things, and fight, and attack 
those near them. My experience is that not more than one in fifty mel- 
ancholies is homicidal in any degree, and not more than one in a hun- 
dred is dangerously so. 

It must always be remembered that a large number of patients do not 
confoiTQ strictly to any of those varieties of melancholia, or pass from 
one variety into another, or have the characters of two or even three of 
the varieties. The following is such a case, which also shows, what 
always exists to some extent, but in some patients more markedly than 
others, viz., that melancholia is a brain storm, or convolution stomi 
rather, which arises gradually, gathers strength, and reaches its acme, 
after which it slowly loses its morbid energy and passes away. During 
its height it often nearly kills the patients by exhaustion, as in this case, 
and would kill oftener if means were not adopted to counteract its effects. 

B. S., set. 50. Single. Xo occupation. Fair education. Disposition 



STATES OF MENTAL DEPRESSION. 113 

reserved. Habits correct and temperate. One previous attack of mel- 
ancholia, duration under a week, treated at home. No hereditary pre- 
disposition to insanity or other nervous disease. Predisposing cause, 
previous attack. Exciting cause: change of life. First mental symp- 
toms : had some domestic grief which greatly upset her, became unsettled 
and depressed, and assigned groundless reasons for her grief. Has 
since become taciturn, and refused food for two days, sleepless ; not 
epileptic, suicidal, or dangerous. Duration of existing attack : six days. 
Great depression, constant restlessness, moaning and complaining, 
taciturnity when questioned, refusal of food and medicine. 

On admission: great depression, will not answer a single question, 
keeps constantly moaning and crying "Oh! oh!" looks very miserable, 
wanders about the room incessantly wringing her hands. Memory and 
coherence cannot be tested ; will not attend to questions. Seems to have 
delusions of a melancholic character. Is a thin, middle-aged lady. 
Muscularity and fatness poor. Appetite absent. Pulse 108, regular but 
small. Temperature, 99.4°. General bodily condition very weak. 

First night in the asylum was very restless, kept up a constant wail of 
"Oh! oh!" Could with difficulty be got to swallow a little fluid food. 
"Typhoid" expression; very sallow look; dark ring round eyes; dry, 
scaly lips ; temperature, 99.2°. This state continued and increased for 
about a fortnight without improvement. Very sleepless ; constant 
piercing w^ail, very distressing to other patients. Her weakness was 
extreme. She was entirely confined to bed and fed every half hour 
with liquid food, milk, eggs, beef-tea, and a large quantity of w^ne. She 
then began to improve and was much better in the mornings, and got 
worse in the afternoons. Could be induced to speak intelligently ; 
looked less depressed ; took a fair quantity of food ; slept better. 
Within another week she was quite convalescent, gaining in flesh and 
strength very rapidly. At the same time desquamation occurred (this I 
have seen in several patients after such short acute attacks). Still a want 
of appetite. Two weeks later sent out on pass. Appetite and general 
health improved. Residence in asylum four weeks and ten days. 

There are a few cases of depressed feeling with exalted intellectual 
condition. Many patients exaggerate their former happiness, wealth, 
and position by w^ay of contrast with their present misery. I had a woman 
in excited melancholia, groaning all the time, who fancied herself a 
queen ; another w^ho had immense wealth. Some of the cases are of the 
nature of what the French call megalomania, that is, the expansive 
grandiose exalted state of mind which, as a mental symptom, is best seen 
in general paralysis, coupled with ideas of persecution, and with depressed 
feeling, especially at times. 

The Inception of Melancholia. — It begins in nearly all patients as 
simple lowness of spirits, and lack of enjoyment in occupation and 
amusement, and loss of interest in life. This may be premonitory of 
the disease by months or even 3^ears, and happy is the man who then 
takes warning, and adopts proper treatment. The next stage is tliat of 
the simple melancholia described in A. B's. case (p. 57), and this may be 
of long or short duration, and may pass into one of the other and more 
serious varieties. As a general rule tlie hypochondriacal variety is 

8 * * 



114 STATES OF MENTAL DEPEESSION. 

longest and slowest in inception. I have seen the delusional, the suicidal, 
and the excited varieties fully developed within a week of the commence- 
ment of the first symptoms, but this is rare. I have seen the loss of 
self-control take place quite suddenly, a man being calm externally, though 
dull, in the early morning, and by ten o'clock a.m. in the acutest stage of 
suicidal and excited melancholia. Many patients exercise self-control 
strongly for a time, and then at once lose it. This, however, is not 
common. The duration of the disease previous to the admission of the 
case into an asylum is a good test of the rapidity of progress of the 
disease in its full stages up to the time that self-control was so lost as to 
require treatment and restraint in an institution. Of three hundred and 
sixty-five cases in which information on this point was obtained, forty 
per cent, had been melancholic for periods under a month before admis- 
sion ; sixteen per cent, for periods from one to three months ; eight per 
cent, from three to six ; and the remaining thirty-six per cent, over six 
months. 

The delusions in many cases take their shape, if not their origin, in 
painfal or disagreeable sensations in the organs, which are misinterpreted 
by the disordered mind, and attributed to wrong causes. The power of 
morbid attention on feelings is very great in exaggerating them, and even 
in creating them, in persons of the nervous diathesis. In some cases a 
paralysis of the consciousness of natural afi"ection is the first symptom of 
melancholia, and the patients, thinking that they no longer love their 
children, get depressed. I have known in a few cases a craving for 
stimulants to be the first symptom. I knew a lady in whom this was so 
each time she became melancholic, which she did at each pregnancy and 
at the climacteric period. 

The ages at which melancholia comes on are more advanced, on the 
whole, than in the case of mania (see Plate VI.). Four per cent, only 
come under twenty ; only twenty per cent, under thirty. The largest 
proportion of cases in any one decennial period (twenty-five per cent.) 
occurred between forty and fifty, while there was twenty-three per cent, 
between thirty and fifty ; eighteen per cent, between fifty and sixty ; and 
fourteen per cent, over sixty. 

Bodily Symptoms of Melaxcholia. — The premonitory bodily 
symptoms that 1 have most commonly met with have been headaches, 
neuralgia, confused feelings in head, want of appetite or indigestion, cos- 
tiveness, a feeling of weariness and languor, in some cases restlessness, in 
others "biliousness," oxaluria, and, above all, the two symptoms of 
sleeplessness and loss of body weight. When the mental symptoms 
become fairly developed, the headache and neuralgia, if present, usually 
disappear, and we have, instead, a brilliancy of the eye, a tendency for 
the temperature to rise a little at night, a hebetude or some other change 
in the facial expression, a furred tongue, which, in four cases out of five, 
is neurotic, resulting from the deficient innervation of the stomach. The 
want of appetite often becomes a repugnance to food, the sleeplessness 
becomes complete, the constipation great ; in about fifteen per cent, there 
is a temperature over 99.5°. Taking three hundred and sixty-five cases 
at random 1 found constipation in fifty per cent. ; sleeplessness in sixty 
per cent.; want of appetite in sixty per cent.; pyrexia in fifteen per 



STATES OF MENTAL DEPRESSION. 115 

cent. ; and hallucinations of the senses in twenty-five per cent. ; epigastric 
pain and sinking in a few; headaches and sensations of binding, of 
weight, and emptiness in the head in a few ; heart disease in a few ; 
suppression of discharges in a few ; disappearance of skin disease in a 
very few. Taking the general bodily health and condition, I found I had 
put thirty-six per cent, as being in fair general bodily condition on 
admission ; fifty-seven per cent, as weak and in bad condition ; and seven 
per cent, as very weak and exhausted. The heart's action is markedly 
affected in all the acute cases and in many of the others. In the former 
the condition of hyper-action in the brain seems to exercise an inhibitory 
influence on the cardiac-motor innervation, causing the pulse to be small, 
the arterial tone to be low, and the capillary circulation to be very weak 
indeed. The skin is in the acute cases greasy, perspiring, and ill-smelling, 
In most patients, however, it is hard, dry, harsh-feeling, and non-perspir- 
ing. Sometimes we have boils (a good sign often) and subacute inflam- 
mations. 

Causation of Melancholia. — The causes of melancholia are always 
popularly supposed to be some calamity, some afiliction, some remorse, 
or religious conviction, that has produced grief and sorrow. As physi- 
cians, we know how utterly far this is from the truth. If I were asked 
my opinion, I should say without hesitation that more melancholia re- 
sults from innate brain constitution than from all outside calamities and 
afilictions of mankind put together. If a man has a well-constitutioned 
brain, he will, like Job, bear calmly all the afilictions and losses that the 
spirit of evil can invent for him. It is impossible to make such a man 
a melancholic. That needs some innate weakness, some predisposition, 
some potentiality of disease, some trophic or dynamical defect. The 
friends of melancholic patients will always assign a cause for their disease. 
To them the occurrence of such a state of matters, without some mani- 
fest cause, seems an impossibility. Who ever saw a newspaper account 
of a suicide without either a cause being stated, or a remark implying 
that there must have been some outside "cause?" A hereditary predis- 
position to mental disease was admitted in about thirty per cent, of the 
cases of melancholia sent to the Royal Edinburgh Asylum, but that is 
very far from representing the truth. I have no ofiicial statistics on the 
point, but my general experience agrees with that of others, that states 
of depression of mind are hereditary more than most morbid mental 
symptoms. I have known several fiimilies where, for four generations, 
a considerable proportion of each was depressed in mind more or less. 
Certainly the tendency to suicide is very hereditary. Next to heredity 
come as causes disordered bodily functions, and after them, at a long dist- 
ance, moral and mental causes of depression. Domestic afiliction is by 
far the most frequent of the last in the fenuile sex, and business anxie- 
ties in the male sex. 

Prognosis. — Out of the last thousand cases admitted to the Morning- 
side Asylum, fifty-four per cent, have recovered. AVithin the seven 
years, under one per cent, have died of the direct exhaustion from the 
disease while recent. The liability to relapse after recovery is best 
represented by the number of previous attacks, Avliich had existed in 
about one-third of all the cases. It must be remembered that those sta- 



116 STATES OF MENTAL DEPKESSION. 

tistics refer to cases so ill as to need asylum treatment. I have no doubt 
that if the milder cases treated at home were included, the recovery rate 
would be much greater. 

The things that enable us to form a good prognosis are youth ; sudden 
onset; an obvious cause that is removable; want of fixed delusion; 
absence of hallucinations of hearing, taste, or smell ; no visceral delu- 
sions ; no strongly impulsive or epileptiform symptoms ; no picking of the 
skin, or pulling out the hair, or such trophic symptoms ; no long-con- 
tinued loss of body weight in spite of treatment; no long-continued in- 
attention to the calls of nature, and no dirty habits. 

But be guarded in giving a definite prognosis in almost every case. 
The greater my experience becomes, the more guarded I am. Some of 
the most favorable looking cases will deceive you, while some that look 
most hopeless will recover, as in the case of B. S. A., a patient of mine, 
who had been seven years melancholic, suicidal, and sleepless, and who 
recovered at seventy-four, and is now quite well, and doing her house- 
hold work. 

The bad signs are a slow, gradual onset, 'like a natural evolution; 
fixed delusions, especially visceral and organic delusions ; gradual decay 
of bodily vigor; persistent loss of nutritive energy and body weight; 
convulsive attacks and motor afiections generally, not ideo-motor; per- 
sistent hallucinations, especially of hearing, smell, and feeling; picking 
the skin or hair ; persistent refusal of food ; an unalterable fixity of emo- 
tional depression of face, or persistence of muscular expressions of mental 
pain (wringing hands, groaning, etc.); persistent suicidal tendency of 
much intensity ; arterial degeneration ; senile degeneration of brain ; no 
natural fatigue following persistent motor eiForts in walking, standing, 
etc.; a mental enfeeblement like dementia. 

Termination of Melancholia. — Of the cases that terminated in 
recovery, fifty per cent, recovered within three months, seventy-five per 
cent, under six, eighty-seven per cent, under twelve months, leaving only 
thirteen per cent, who took more than a year to recover. 

In most cases, recovery is gradual. In my experience, an improve- 
ment in the bodily condition and looks, and an increase in the body 
weight and appetite, alwa^^s precede the mental improvement. The 
motor restlessness generally passes ofi" first. The patients sit down and 
do work of some sort; then they begin to eat better; then the delusions 
lose their intensity ; then the sense of ill-being is less oppressive. There 
is often an irritable stage as improvement sets in. I have one patient 
whom I am always glad to hear swearing: I know then that he is going 
to recover. The return of the sense of well-being is the last to come, 
and along with it that surplus stock of nervous energy that constitutes 
health. A man whose nerve capital is always running low can never be 
said to be in really good safe health. When I see a patient taking on 
flesh at the rate of three or four pounds a week, I know he is safe, and 
will make a good recovery. The only exceptions to this are in the 
long-continued cases, where the mental functions of the convolutions are 
permanently enfeebled and damaged, and in whom, as the depression 
passes ofi", we have a fat dementia resulting. This, however, is much 
more uncommon in melancholia than in mania. Some patients — a few 



STATES OF MENTAL DEPRESSION. 117 

— make sudden recoveries in a few days. I have even seen a patient 
go to bed very melancholic, and get up quite well, saying — " I see that 
all these fancies were mere nonsense. I wonder I could have been such 
a fool as to believe them." 

A few of the cases end in the chronic melancholia I have described. 
They are nearly all middle-aged or old people. Many of the cases 
pass into mania; a few become alternating insanity; and a few pass 
into dementia, which, in that case, is never so complete and absolute a 
mental enfeeblement as when it follows mania. 

Summary of Treatment of the States of Mental Depression. 
— If the brain and body conditions that accompany, if they do not 
cause, states of morbid mental depression are those of trophic deficiency, 
as we have seen is undoubtedly the case in most instances, then it neces- 
sarily follows that what will remedy those conditions is indicated, and 
all things that will aggravate them must be avoided. Even in the 
patients where there is no demonstrable lack of brain or body nourish- 
ment, and where the disease is more of a purely dynamical brain dis- 
turbance, and a disordered enero-izino; of the convolutions from heredi- 
tary instability, yet in such cases there is lack of force and vitality in 
the brain. We make the conditions of life of a melancholic, therefore, 
as physiological and favorable as we can. Every therapeutic agent whose 
eifect is tonic, hunger-producing, digestive, vaso-motor, and generally 
nerve-stimulating we give. Quinine I place in the first rank ; iron, the 
phosphates, hypophosphates, strychnine, phosphorus, etc., in the second; 
and the mineral acids, vegetable bitters, aloes, arsenic, gentle laxatives, 
cholagogues, diuretics, and diaphoretics in the third. Not that I have 
not seen quinine and strychnine over-stimulate, and have to be stopped, 
and iron determine blood to the brain in a way to do harm, but those ill 
effects are rare, and they can be stopped as soon as observed. The 
mineral waters of our own country, and especially of Germany, come 
under the same category as those tonics. Many a commencing melan- 
cholic have I seen cured most pleasantly by a short stay in Schwalbach, 
Wiesbaden, Carlsbad, etc. Of course, the particular kind of water 
must be determined by the diathesis — the purely chalybeate to the 
purely neurotic, the saline to the gouty and rheumatic, etc. The con- 
tinued current, applied not too strong, and passed through the great 
nervous centres, is greatly trusted by some Continental physicians, and 
I have seen it do good in patients with the element of stupor present. 

Diet and regimen are of the highest importance. If I were as sure of 
everything else in therapeutics as this, that fresh air and fattening diet 
are good for melancholic people, I should have saved myself many medical 
questionings. Such patients cannot have too much fresh air, though they 
may have too much walking, or gymnastics, or muscular fatigue. It is 
the best sleep-producer, the best hunger-producer, and the best aid to 
digestion and alimentation. Without it all the rest is totally useless in 
most cases. Patients cannot fatten too soon or too fast, though their 
stomach and bowels may be overloaded, and their livers and kidneys may 
be too engorged. Fatty foods, milk, ham, cod-liver oil, maltine, eggs, 
farinaceous diet, easily digested animal food, such as fish, fowl, game, etc., 
are my favorite diet for melancholies. Milk, in very many cases, is my 



118 STATES OF MENTAL DEPEESSION. 

sheet-anchor. I have given as much as sixteen tumblers a day with 
surprising benefit. The nervous diathesis does not put on fat naturally, 
therefore we must combat the tendency to innutrition by scientific dieting. 
Adipose tissue and melancholia I look on as antagonists ; therefore when 
we want to conquer the latter we must develop the former. I need hardly 
say that the capacity of digestion, the peculiarities of digestion, arid the 
dietetic likings, and even the idiosyncrasies of our individual melan- 
cholies, must be studied. A good cook is an aid to all cases, a pleasure 
to most, and a necessity to some. 

Concerning stimulants, I certainly have found them useful in many 
cases. The fattening appetizing ales and porters work wonders on some 
lean anorexic melancholies. Good wines do the same. Claret or Bur- 
gundy are the chief, wdien suitable to the circumstances of the patients, 
that do good. The stronger stimulants are only needed in the exhausted 
cases, except, indeed, when whiskey and w^ater at bedtime is a good 
soporific. Be sure, however, that it is not the hot water alone that 
causes the slee23. I have seen a tumbler of hot water taken at bedtime 
cause sleep as quickly as when mixed with a glass of whiskey, and have 
a better efiect altogether. When a patient begins fairly to gain weight, 
all alcoholic stimulants may be discontinued, except as mere luxuries. 
Change of air ; mountain or sea breezes ; change of scene ; quiet in most 
cases ; active travel and bustle in a few of the less serious cases ; long 
voyages, if we are quite sure that the disease does not threaten to be 
acute — all these things are helpful. We enjoin rest from exhausting or 
irritating w^ork ; above all, escape from w^orry. We bring a diff"erent set 
of faculties and a different group of muscles into action from those that 
have been employed before. Do not push anything that is too great a 
conscious effort for the patient to do. Do not send a man to fish if fishing 
is a disagreeable toil, or make him go into "cheerful society" when this 
is a real torture to him. Pleasant society with no bustle, beautiful 
scenery, music, and sunshine, are all healing to melancholy. In most 
cases some occupation that is a pleasure has to be encouraged, and does 
much good. Fishing, easy mountaineering, shooting, boating, out-door 
games, are most suitable for certain cases. We try and make the im- 
pressions received by the senses agreeable, and, therefore, harmonious 
with the well-being of the organism. We try and substitute pleasurable 
feelings for painful ones by every means known to us. Slow travel, with 
a cheery, sensible companion, who is, of course, twice as valuable if he is 
a doctor, saves many a man from an asylum. In most cases we remove 
a man temporarily from his wife and family, for paralyzed or perverted 
affection to a melancholic is itself a painful thing and a source of de- 
pression. But there are marked exceptions to this rule — cases where a 
man's wife is the best nurse, his children his best companions. In bad 
cases a cheerful trained attendant and a young doctor make a capital 
team for the melancholic who needs attention, company, and medical 
supervision. We try to remove the patient from surroundings that are 
depressing to those that will rouse pleasant thoughts, and to take him 
from the place where his malady arose. Everything and every person 
there may suggest pain to him. But he must not always have his own 
way. Quite the contrary. In most instances another will must over- 



STATES OF MENTAL DEPEESSION. 119 

come his own, and be substituted for it. This is a reason why mothers, 
wives, and sister do harm, because they let the patient have too much of 
his own way. It is certainly well if those about him have physiologically 
a surplus stock of animal spirits to infuse into him. Much tact is needed 
in personal intercourse with melancholies, as, indeed, with all the insane. 
Never argue with them on any account, or contradict their delusions. 
Do not agree with them, but change the subject. Discourage introspec- 
tion, encourage observation of, and talk about things without them. 
Every neurotic man should have an out-door hobby. That would save 
many of them from melancholia. 

Gruard against suicide, and make the friends and attendants feel that 
there is a real risk of its being committed. They get into the state of 
mind of railway porters, who are so accustoujed to risks that they do not 
guard against them. I have seen suicidal melancholies by the dozen, 
about whom I had given warnings as strong as I could make them, that 
every article by which suicide might be effected should be removed, and 
yet found knives in their pockets, and razors in their dressing-cases. 
The bad cases should never be left alone. I once had a suicidal patient 
under the charge of an attendant, who was said to be experienced, and I 
found my patient in a top-story room alone, with a loaded revolver in his 
pocket, and a razor case in his room, and yet his mother and his attendant 
did not seem to see how great the' risk had been. 

Many melancholies are intensely selfish, think of nobody but them- 
selves, bore their friends with recitals of their own feelings, and crave 
sympathy with a morbid intensity. Too much expressed sympathy in 
most cases feeds the disease. To distract the attention from morbid 
thoughts and feelings by any means should be the one great aim in per- 
sonal intercourse. Strangers often do better with melancholies than 
friends. Many of them take most strong and unfounded morbid dislikes. 
They exercise more self-control before strangers, and the strengthening 
of the power of self-control is half the cure. That is why removal to an 
asylum is sometimes followed by immense benefit. A patient who at 
home has been groaning, noisy, idle, and unmanageable, finds himself 
among strangers subjected to rules and discipline and ordinary living, 
and has objects of fresh interest presented to him, and he becomes a 
different man at once. I asked a man who had been very ill and un- 
manageable at home, and who seemed to come round in a few days in 
the asylum, what had cured him ? His reply w\as, '' I found myself 
among a lot of people who did not care a farthing whether I was miser- 
able or not, which made me angry, and I got well." Being by far the 
most conscious form of insanity, it would seem the hardest on the patients 
to send them to an asylum, but in reality removal to an asylum does 
more good to certain melancholies than to any other class of the insane. 
What is good is not always pleasant in mor^il as well as in medical treat- 
ment. There is no use dunning a patient to "rouse yourself," to ''throw 
off your dulness," to "drop these fancies," for in many cases it would 
just be as wise to tell a hemiplegic to " move that leg." 

Good nursing in the weak cases, just as you would nurse a fever patient, 
is of the last importance. A nurse that will insist and persist, till the 
insane opposition and the repugnance to food are overcome, is wliat wo 



120 STATES OF MENTAL DEPEESSION. 

want. It is most easy to let a melancliolic slowly starve himself, while 
he yet takes some food at every meal. 

As regards the sending a patient to an asylum, and when to do it, no 
rules can be laid down. Among the poor it must be done in nearly 
every case, and soon, though now-a-days a working man can get a com- 
plete change of air and scenery for a shilling. Among the very rich, 
few melancholies are sent to asylums till their relations are tired out with 
them, or they become very suicidal. No doubt the risks of suicide are 
much less in an asylum. There are discipline, order, a life under medical 
rule, suitable work, much amusement, and the means of carrying out 
what is good for the patient. When from any cause you cannot get the 
treatment carried out that you know is necessary for the patient, then an 
asylum is needful. When the symptoms persist too long without showing 
signs of yielding, when the risk of suicide is very great, when the patient 
has foolish friends who will not carry out any rational plan of treatment, 
or when he gets too much sympathy, or none at all — in all these cases 
an asylum is indicated. Many patients who resist all right treatment at 
home will submit to it at once in an asylum. 

Baths are most useful, especially Turkish baths. I have seen many 
chronic incurable melancholies much improved by a course of Turkish 
baths. The wet pack is often useful. One great difficulty one has in 
treating a case of melancholia is whether to give narcotics and sedatives, 
when to give them, what to give, and when to stop them. Opium I 
utterly disbelieve in. I performed a series of elaborate experiments with 
it in melancholia,^ and it always caused a loss of appetite, and loss of 
weight in every case, and Dr. Mickle has confirmed these results.^ I 
have only seen one melancholic in which I was sure opium did good. 
Chloral is most useful as a temporary expedient to get sleep. I now 
always give small doses — never more than twenty-five grains, generally 
keeping to fifteen, combined with from twenty to fifty grains of the 
bromide of potassium or sodium or ammonium. But I now seldom give 
chloral long. I am satisfied that one effect of its prolonged use is to 
reduce the tone of the nervous system, and to lessen the power of en- 
during pain, mental or bodily. The bromides, too, when long given 
are depressing. Tincture of henbane, in doses from one drachm to four, 
is very useful as a temporary expedient in the very agitated cases, and 
so is conium ; but, of all the narcotics, I have found a mixture of tinct. 
cannabis indica (from x. min.) and bromide of potassium (from xx. grs.)~ 
do the most good and the least harm to the appetite for food. We have 
not yet discovered the narcotic that gives brain-quiet, combined with in- 
creased appetite and body weight. Tinct. lupuli I have found of much 
service in some mild cases, and it did no harm whatever. 

I have seen many cases cured by a crop of boils, a carbuncle, or an 
attack of er3^sipelas, and in one case by an attack of dysenteric diarrhoea. 
I think we shall some day be able to inoculate a septic poison, and get a 
safe manageable counter-irritant and fever, and so get the " alterative " 

1 " Fothergillian Prize Essay for 1870," Brit, and Toreign Med.-Cliir. Keview, 
October, 1870, and January, 1871. 
^ Practitioner, June, 1881. 



STATES OF MENTAL DEPEESSION. 121 

effect of such things, and the reaction and the stimulus to nutrition which 
follow febrile attacks. 

Prophylaxis in Melancholia. — I think our profession could di- 
minish the amount of melancholia if they were consulted sooner and 
more as to the prophylaxis in patients who have had, are threatened 
with, or who are predisposed to, states of mental depression. Especially 
is the preventive aspect most important in the dieting, regimen, educa- 
tion, and work of the children of this class. If we could make all these 
things counteractive of the temperament and heredity, instead of being 
developmental of them, we could do much good, and prevent an enormous 
amount of unhappiness in the world. It is surprising how soon such 
children show their brain instability. A "too sensitive" child should 
always be looked after. Children of this class take "crying fits" and 
miserable periods on slight or no provocation. We do not call these 
things melancholia, but depend upon it they often have a close kinship 
to it. Such children should be kept fat from the beginning ; they should 
get little flesh diet and much milk till after puberty. Their brains should 
not be forced in any way. They should be much in the fresh air. They 
should not read much imaginative literature too soon. They should be 
brought up teetotalers and non-smokers. They should sleep much. Public 
school life is often most detrimental to them. If they are bullied, they 
suffer frightfully. (Read poor Co^Vper and Lamb's lives.) If they are 
taught masturbation, it takes a frightful hold of them, and it is they wdio 
are ruined by it in body, mind, and morals. The modern system of 
cramming and competitive examinations are the most potent devices of 
the evil one yet found out for the destruction of their chances of happi- 
ness in life. Such children are often over-sensitive, over-imaginative, 
and too fearful to be physiologically truthful ; tend under fostering to be 
unhealthily religious, precociously intellectual, and hypersesthetically con- 
scientious. Now, a wise physician will fight against the average school- 
master in all these things. Such children should be taught to systematize 
their time and their lives, to develop their fat and muscle, and to lead 
calm lives of regular, orderly occupation. 

As regards the prophylaxis in those who have already suffered from 
melancholia, at the risk of being thought to ride a hobby, I tell such 
persons, one and all, to keep fat. Let them take precautions in time. 
The falling off of a few pounds in weight may be to them the first real 
symptom of the disease returning, even though they feel at the time as 
well and hearty as possible. It is at this stage that change and rest do 
real good. I always advise my recovered melancholic patients to weigh 
themselves every month, and keep a record of their weight, to lead a 
regular life, and to practise system and order in their work. Reducing 
their ordinary lives to a routine is the safest thing for them if they can 
do it. Like leanness, want of system and method go with a tendeiuy to 
melaucliolia, in my experience. They sliould not work, or think, or feel 
in big s})urts. And as the crises of life — the climacteric, pregnancy, 
child-birth, and senility — approach, let special care be taken by them. 
Do not let them get to depend on soporifics for sleep. Nothing is more 
dangerous. An hour's natural sleep — "tired nature's sweet restorer" — 



122 STATES OF MENTAL DEPRESSION. 

is worth eight hours' drug-sleep. A country life, with much fresh air, is 
no doubt the best, if it is possible. Eegular changes of scene, "breaks" 
in occupation, and long holidays, are, of course, most desirable for some 
people. Though travel and change are very often harmful to actual 
melancholic patients, yet, to many persons who merely have the tempera- 
ment and the tendency, they are most effective in warding off attacks. I 
know several people who in that way keep well and moderately happy. 
The great thing to be avoided is too fatiguing travel — seeing too much in 
too short a time. 



LECTURE IV. 

STATES OF MENTAL EXALTATIOI!^— MANIA {PSYCHLAMPSIA). 

Like conditions of mental depression, states of mental exaltation, up 
to a certain degree, may be normal and physiological. This is especially 
apt to be the case in persons combining the sanguine temperament and 
the nervous diathesis. Every one has met with the sort of person who 
is easily elated, has little power of controlling the outward manifestations 
of exalted emotion, is quite carried away by joyous news or pleasurable 
feeling, so that he talks loud and fast, cannot sleep, cannot rest, acts in 
strange, excited ways, and perhaps dances and sings — all without a cause 
that appears sufficient to produce these effects. Such conduct may be 
perfectly natural and physiological in any man, if the cause be sufficient ; 
but, in the Teutonic races, at all events, such causes do not occur very 
often in the adult lifetime of an ordinary man. If such mental exalta- 
tion does occur in any one on quite insufficient cause, or if it continues to 
manifest itself long after the cause has operated, we say that such a 
person is of an "excitable temperament." Many bodily diseases in 
persons of this constitution are apt to be accompanied, and are often 
much complicated, by such brain excitement. 

Mental exaltation is perfectly natural in childhood. It is, in fact, the 
physiological state of brain at that period. Hence, whenever the tem- 
perature of the brain rises from febrile disorders in children, we are apt 
to have delirious mental exaltation. But if a grown man exhibited the 
same symptoms of mental exaltation as a child, it would be accounted 
morbid, and he would be reckoned insane. In children of the constitu- 
tion I have referred to, this is apt to become a most serious complication. 
While a high temperature is apt to cause violent delirium in such 
children, it is in them, too, that reflex peripheral irritations, such as 
teething, worms, undigested or indigestible food in the stomach, cause 
convulsions. In adults of this constitution, a febrile catarrh, a mild 
attack of rheumatism, or gout, or inflammation may be most serious 
matters, from the sleeplessness, nervous excitement, intensity of the pain, 
or the delirium present. All febrile affections act as a match to gun- 
powder in such a brain. The exaltation and delirium are usually con- 
temporaneous with the beginning and acme of febrile attacks, while 
depression of mind follows the disease. I consider that tlie bodily 
temperature at which delirium begins in a child is a good index of its 
brain constitution and temperament. I have known a very nervous 
child always delirious if its temperature rose to 100°, while in most 
children this does not take place till it is 10:2° or over. Then, apart 
from increased temperature, such children are subject to gusts of unrea- 
soning elevation, during which they are quite beside themselves, rushing 



124 STATES OF MENTAL EXALTATION, 

about wildly, shouting, fighting, and breaking things, not really knowing 
what they are about, this coming at intervals like the "attacks" of a 
disease. Most sorts of blood-poisons, many drugs, such as opium, 
henbane, Indian hemp, and alcohol, as well as an increase of body tem- 
perature, readily cause maniacal exaltation in the brains of which I am 
speaking ; and I have seen such usually temporary exaltation not pass oif, 
but become a prolonged attack of mania in several patients — one after a 
dose of cannabis indica, another after opium, and more than one after 
alcohol. All were, of course, strongly predisposed to insanity by heredity. 

There is much less difficulty in drawing the line in most cases betw^een 
sane, or even between merely delirious exaltation, and pathological insane 
exaltation, than between the conditions of sane and insane depression of 
mind, though many individual cases of difficulty are met with. The 
reasoning power — that of judging rightly, and comparing — is afi'ected 
sooner and more decidedly in mania, and the loss of control in action, 
conduct, and muscular movements is also sooner seen. That stage of 
loss of memory and consciousness where the personality is lost, and the 
former mental life and experiences have disappeared, where in fact 
the metaphysical ego has fled, and a false consciousness — an unreal ego — 
has taken its place, is far sooner reached in mania than in melancholia. 

The name Mania is apt to be used both professionally and popularly in 
a loose Avay as synonymous with insanity, or even to indicate a mental 
craze or eccentricity that falls short of that. This is a very great pity, 
for we shall never in mental diseases make satisfactory progress till we 
get an accurate scientific nomenclature. The loose way in which the 
present terms are used is certainly an excuse for those who, like the late 
Professor Laycock, coined a new medico-psychological terminology 
altogether, to express morbid mental conditions. Nothing is more 
common than to see in medical papers "suicidal mania," when "suicidal 
melancholia" was meant. It is necessary, therefore, to define the term. 
Mania might be defined as morbid mental exaltation or delirium, usually 
accompanied by insane delusions, always by a complete change in the 
habits and modes of life, mental and bodily, by a loss of the power of 
self-control, sometimes by unconsciousness, and loss of memory of past 
events, and almost always by outw^ard muscular excitement, all those 
symptoms showing a diseased activity of the brain convolutions. We 
think of melancholia chiefly from the patient's subjective point of view, 
taking his affective change and his conscious mental pain chiefly into con- 
sideration, while we think of mania more from our own objective point of 
view, and picture the patient's talkativeness, his restlessness, and his mani- 
fest changes of personality and habits : just as in neuralgia we think 
of the patient's sensations, and in tetanus of the convulsions Avhich we 
see for ourselves. The definition of mental exaltation, too, must not be 
taken as if it were the mere opposite of depression or of mental pain. 
Mental exaltation in its medico-psychological sense is not consciously felt 
mental pleasure. It may be that, but as, in most cases of acute mania at 
all events, we have the unconsciousness of former mental acts as w^ell as 
of present circumstances, this definition could not properly apj)ly to these 
cases. I Avould, therefore, define morbid mental exaltation to be a mor- 
bidly increased production of mental acts by the brain with or without an 



STATES OF MENTAL EXALTATION. 125 

increased sense of well-being or pleasure, but distinctly without a conscious 
sense of ill-being or mental pain. The word excitement used medico- 
psjchologically refers always to outward visible muscular acts, such as 
restlessness, muscular resistance, acts of violence, shouting, facial expres- 
sions, contortion, or movements or expressions of the eyes, or to an 
intense desire towards such acts restrained by a strong exercise of self- 
control. 

Most melancholic patients can tell us how they feel. They know there 
is something wrong with them, exaggerating their mental pain ; while in 
most cases of mania the patients affirm they are quite well, probably 
better than they ever were in their lives, and we have to judge of their 
mental condition from their speech and actions, which become to us the 
symj)tomsoi the disease. 

If we look at a number of patients who are all classified as laboring 
under mania, we see at once that there is a very great difference, indeed, 
between different cases. Without going into pathology or causation at 
all, the outward manifestations show not only far greater intensity of 
morbid action in different instances, as is the case in all diseases, but 
a difference of type of symptoms, mental and bodily, which I shall 
endeavor to assort for clinical and practical purposes into varieties of the 
disease ; it being understood that these varieties are not necessarily 
distinct diseases or pathological conditions, but merely groups of similar 
symptoms that may be combined with other groups, or may be different 
stages, in the same disease. The great advantages of classifying mania 
into those varieties are, that thereby a student is less confused in seeing 
patients so very different from each other, and more especially in the guide 
that is thus obtained in treating and managing patients. The varieties I 
propose to describe and illustrate by clinical cases are — a. simple mania ; 
h. acute mania; c. delusional mania; d. chronic mania; e. ephemeral 
mania {mania transitoria); and/, homicidal mania. 

Simple Mania. — When a man of common sense, who has been of the 
ordinary type as to conduct, demeanor, and speech, undergoes, without 
outward cause, such an intellectual change that he becomes loquacious, 
talking constantly to every one who will listen to him about anything 
under the sun, especially his own private affairs — when his judgment is 
manifestly not to be depended upon, and his views as to himself, his 
prospects, his capacities, mental and bodily, and his possessions mani- 
festly exceed what the facts warrant — when he becomes fickle, restless, 
unsettled in his conduct, and foolish in his manner — when he acts without 
motive and without aim — when, in fact, his common sense has gone, and 
his power of self-control has become manifestly lessened, and when this 
lasts for days or weeks, we say he labors under simple mania. This 
condition would seem at first sight an easy one to describe. But it is 
not so; for though it seems simple, yet, when we come to analyze the 
mental faculties involved, and how tliey are affected in different cases, 
we find an immense variety of combinations. No one case is quite like 
another any more than any one man's mental development is like that of 
another. A condition of morbid mental exaltation may exist, and I 
believe does occur, among persons of a nervous heredity, far more fre- 
quently than is commonly sui)posed in slight forms that are not con- 



12G STATES OF MENTAL EXALTATION. 

sidered insanity at all. I would go the length of placing the "lively 
moods" to which some people are subject in the category of a direct kin- 
ship to simple mania, just as I would place the "dull moods" of some 
people among the relationships of simple melancholia. 

The longer I live, the more I am impressed Avith the fact that some 
of the important acts in the lives of certain persons are the result of 
brain conditions that cannot be reckoned as being quite normal. The 
men whom one knows as subject to restless, energetic, boisterous fits 
lasting for weeks, who do childish, extravagant, or foolish things at these 
times, whose natural peculiarities are then much exaggerated, and whose 
common sense seems to ebb and flow in an unaccountable way, are of 
this class. If we inquire into the family history of those persons, we 
are almost sure to find a nervous strain. We will usually find, too, that 
the more we take to studying the practical psychology of our fellow-men 
from the point of view of heredity and brain function, the more will 
those peculiarities impress us as being the same in nature, but less in 
degree than those greater mental peculiarities that we call insanity. Not 
that for a moment I want to lessen the moral responsibility of such persons 
to society or the law, or to confuse the great assumption that underlies all 
social arrangements and all law, that all men are sane and responsible 
until proved by good evidence not to be so. Still the field I am indi- 
cating is a most interesting one in the study of human nature. I have 
know^n great fortunes lost and even made ; great enterprises undertaken ; 
great speeches made; great reputations impaired; unsullied characters 
stained irretrievably in the public eye ; ancient families degraded; mar- 
riages contracted, adulteries committed, and unnatural crimes perpe- 
trated by men and women whom I considered to be laboring under mild 
attacks of simple mania, but whom the world in general simply looked 
on from the ethical and legal point of view. Those persons were the 
victims of "the tyranny of their organization;" yet our medico-psycho- 
logical knowledge will have to be far more accurate and more widely 
diffused before we can save them from it or its direct consequences. In 
such cases, we find that at a certain period in their lives a mental change 
took place. In some way their "characters" underwent an alteration. 
In my experience, by far the greater number of the cases of "moral 
insanity" were of this kind. Most of Pritchard's cases of moral insanity 
I look on as examples of simple mania. Of course, I do not mean those 
cases where no morals had ever come to a person by heredity, education, 
or example, or where the morals and self-control had been deliberately 
destroyed by the mode of living. 

I knew a gentleman, C. A., w^ho was famed in his neighborhood for 
his prudence, probity, and devotion to business, for his wisdom, morality, 
and religion, who, at a certain period of his life, after middle age had 
come on, underwent a total change. He became rash, indifferently 
honest, utterly careless of his business, foolish in his schemes, very 
doubtfully moral, and careless of religion. He changed in his mode of 
dressing, in the company he kept, and his way of living. His affairs 
got entangled, and he lost a fortune by foolish speculation, this being 
entirely new to him. Yet he mingled in society all the time; never said 
a particularly foolish thing; transacted business in a large way of the 



STATES OF MENTAL EXALTATION. 127 

utmost importance to himself and others ; and I should have been very 
sorry indeed for any one who had called him insane to his face, or taken 
steps to abridge his personal liberty, or deprive him of his civil rights 
as a citizen. No jury in the empire but would have held him sane, and 
no judge but would have made his case a text for a homily on the 
danger of medical views in regard to insanity and the liberty of the 
subject. I am never more impressed with the difference between ap- 
pearance and reality than when I hear a judge dogmatically lay down 
the law in regard to intricate points of human conduct and motive, and 
remember that the man's education was probably a most one-sided one, 
with not an atom of science in it, and not a suggestion of the study of 
brain function, that his training was got in an atmosphere where every 
act is assumed to have "a motive;" where the worst motives are com- 
monly assumed, and all men are supposed to have bad motives more or 
less. I venture to say that you will not have been in practice for a year 
before you will have seen many men and women whose conduct will be 
utterly inexplicable, except on the theory that it is the result of their 
brain condition, "motives," as ordinarily understood, having nothing to 
do with it. Well, C. A. got through his fortune, ruined his reputation, 
and scandali-zed and estranged his friends, all without any "motive" of 
the ordinary kind; and all this came on suddenly and in entire opposi- 
tion to the whole tenor of his life, and to every principle that had ever 
held sway over him for twenty years. Yet legally sane he was, just 
because the brain change that I assume was the cause of all this did not 
go far enough to make him lose his self-control entirely, and to act mani- 
festly as a lunatic. Yet can any one who has studied mind from the 
brain point of view doubt that the man's mental acts and conduct during 
his changed period were morbid, and the result of morbid brain action ? 
And this conclusion was vastly strengthened by the fact that his heredity 
was a nervous one, he coming of a family in which insanity and eccen- 
tricity had been prevalent, and that he procreated epileptic children. 
And, by tracing his future life, we find that still without any "motive," 
he again changed, and settled down into a quiet-going, slightly senile 
man, with the fine edge of his faculties and dispositions somewhat taken 
off. In this, as in several others similar that I have met with, such a 
mild attack of mania came on shortly after widowhood. I have seen 
this in both sexes. , My idea is that this was not a coincidence, but that 
the sudden deprivation of sexual intercourse had something to do with 
it in this case as an exciting cause. 

Such is an example of simple mania in its mildest form, not being- 
reckoned insanity at all by the law or by society. I am quite sure that 
you will meet with many similar cases in your practices if you look at 
human conduct from the medico-psychological point of view. And you 
may perhaps save a fortune, or a reputation sometimes, and will cer- 
tainly save much uncharitable recrimination and useless indignation on 
the part of relations by putting them in possession of your knowledge. 
When I am consulted in such cases now, I recommend a long sea voyage 
in a slow ship, or a change of residence for a time, and try and get 
business matters settled on some sort of sure footing, so tliat unsafe 
speculation or falling into the hands of scoundrels may be avoided. 



128 STATES OF MEXTAL EXALTATIOX. 

There is no class of case where harpies seem to fix on a man so inevit- 
ably as in this. Such men are easily led by adroit and unprincipled 
people, who flatter them, and take advantage of their weakness. The 
sort of persons whom the man in his '-right mind"' would never have 
associated with get round him then. He tends to seek persons in a lower 
social and ethical position, and very often the loss of his self-control 
is shown by an excessive use of stimulants, or by frequenting bad company, 
both being mere symptoms of his mental disorder. The lower and baser 
parts of a man, kept under before, now come uppermost. Especially is 
excitation of the sexual desire and disregard of morals and appearances 
in gratifying it most common. I have found this to exist in nine-tenths 
of such cases. I once saved a business and a reputation by getting a man 
in the beginning of an attack of mild mania to take a partner, give up 
business meantime, go to spend a year with a friend on a sheep farm in 
Australia, live out in the open air, take much (but not too much) exercise, 
eat little animal food, and take bromide of potassium in twenty grain 
doses three times a day. This, in fact, sums up about all I can tell you 
in regard to treatment. The great difficulty is that such patients do not 
know that there is anything wrong with them and will not believe it, in 
fact are often most indignant, and quarrel with you if such a thing 
is hinted at. They sometimes look well, but they do not sleep well, and 
all of them are restless, and often worn-looking. They often eat twice 
or thrice as much as usual, and digest their food well. They often 
have their bowels moved twice or thrice a day, even if naturally of a 
costive habit. Their tastes usually change. They lose their fine feelings 
and delicate perceptions of things in taste and smell and sensibilities. I 
have known a man who needed to use highly magnifying spectacles to be 
able to do without them, and even be able to read small print, when 
passing through an attack of simple mania. In fact, I knew a man who, 
as the morbid brain excitement gradually passed away, had to use 
spectacles of greater and greater magnifying power. The body tempera- 
ture is always, I have found, higher by about .5° or 1° during such an 
attack. 

This case was one of great interest, from the natural power of the 
brain affected. C. B. was a man of very high intellectual and scientific 
attainments, with a heredity to the neuroses, of a sanguine temperament 
and robust bodily constitution, great mental energy and acuteness, who 
was prudent, discreet, and held the opinions of others in great respect. 
He had written much and done very good work. At the age of forty-five 
he lost his wife, whom he had sleeplessly nursed, and within a week pro- 
posed marriage to another lady, became excited, took two girls out of a 
brothel, got lodgings for them, tried to reform them, spent money on 
them, prayed with them, and slept with one of them, intending, as he 
said, to make her his wife. And he did some work in a sort of sporadic 
way, not sticking to anything. He slept little, and kept very late and 
irregular hours. Then he developed great brilliancy and social faculty, 
for which he had never been distinguished before. He especially liked 
ladies' society, and he was witty, clever, and had a miraculous memory, 
indeed a better memory than he ever had before. (I knew one man who, 
as he was passing into mania, would repeat a whole play of Shakespeare 



STATES OF MENTAL EXALTATION". 129 

or a book of Milton, which when well he could not do.) He could quote 
long passages from every author he had ever read. Then he began to 
evolve wonderful schemes of all sorts — not quite insane schemes, but 
very nearly so. He got irritable with those who opposed him, and said 
they persecuted him. He went and called on all his casual acquaintances 
of any note, and made new acquaintances on slight cause. He had been 
very fond of his children before, and now he spoke niuch of his affection 
for them, but really he neglected them. He quarrelled with his relatives 
because they remonstrated with him and tried to control him. His next 
stage was a morbid expansive benevolence. He gave away his money 
foolishly to the poor, or to anybody whom he thought needed it. He pro- 
pounded to the philanthropists marvellous plans to terminate the world's 
misery. He went one night, with his Bible in his hand, to a brothel to 
convert its inmates from the error of their ways ; but, after reading and 
prayer, the vice he hated was in one short hour 

" Endured, then pitied, then embraced," 

and he had to leave his Bible in pledge, as he had not sufficient money in 
his pocket! All those things he spoke of freely. Soon after this his 
conduct became so uncontrolled that he was certified as insane and sent to 
the Asylum. But he had succeeded in wasting nearly all his available 
means. When he arrived he was indignant, and made out that his friends 
had ruined his prospects by placing him improperly in a ''madhouse." 
But his indignation was transient and skin-deep. He soon entered into 
the life of the place. He w^as an admirable and interesting talker, a 
copious and sparkling author in the Morningside Mirror^ a hearty if not 
an elegant dancer, a great walker, a scientist, and a devoted admirer of 
all the fair sex, making love indiscriminately to lady patients, nurses, 
kitchen maids, and paupers. And yet he could propound maxims as wise 
as Solomon's Proverbs, and he was a stern and sarcastic censor of morals 
in others. But he had no common sense ; and he could not help making 
a fool of himself if he had the chance. He could not be trusted any- 
where out of the Asylum. He talked about his most private concerns to 
any one who would listen to him. He was very credulous, and in conduct 
he showed small realization of the difference between meum ?indtuum, or 
of the sanctity of the virtues generally. His memory was prodigious ; 
and he was never at rest. His sexual appetites were strong, but not 
really so strong as his erotic imaginations and likings. He told most 
disgusting stories "for a moral purpose" to others, and he was better up 
in the sexual history of great men than any man I ever knew. He 
never got incoherent; he could always control himself for a short time. 
He was always ready with most plausible-looking excuses for his innumer- 
able peccadilloes. "Why should I not kiss that girl and write her love 
letters ? I want to be kind to all persons, and don't you tell me to make 
the best of my present position ? If I lose my temper sometimes, is not 
the natural indignation at the way my friends have used me sufficient to 
account for it? " etc. After havins; one mornino; abused me most heartil 



O ^ ^ "-v..,....j_, 



iv. 



he sent towards evening a letter addressed " Innnediate. The sun has not 
gone down. Morningside. From my prison, wliere, like Joseph, and 
Peter, and Paul, I Avas put on false accusations. My dear Clouston, 1 bog 



9 



130 STATES OF MEXTAL EXALTATIOX. 

jour joardon for speaking to you and of you as I have done. I want some 
liberty. Try and let some patients out, and you will become the greatest 
man of the day. Give the excited ones sedatives like tobacco or better 
food. Dismiss such men — et audi alteram jyartem^ that is, hear my 
version of things. Let me get to town to-day. I need a change. Think 
who I am. Since 1847 the friend of Thomas Carlyle and Alfred 
Tennyson ; of Owen since 1838 ; of Darwin, of Sir John Richardson, 
Rae, etc., etc., etc." (He had casually met these men or called on them 
as he w^as becoming ill.) — "Yours ever." 

'-'• P.S. — Why have you not shown me your children? I do not bite, 
I only bark. 

'' P.P.S. — Read this to any one who may be concerned." 

Persons laboring under simple mania are always in the right, and are 
verv sensitive to criticism and indignant at it. There is much of what 
one can only call cunning. C. B. could control himself for short periods 
when he wished, or when self-control was to bring any advantage ; he 
would pretend to be most friendly Avith the powers that be in the Asylum 
before their faces, and then turn and abuse them behind their backs. He 
would, to strangers, most cleverly make things appear extreme hardships 
that he did not feel as such. He ate enormously and slept badly, but did 
not fall off very much in flesh. 

After six months he was so much better that he was sent to a distant 
part of the country, where he stayed for far too short a time. He made 
an unsuitable marriage with a woman below himself in social station and 
education, had children by her, but soon got tired of her, saying she was 
a prostitute. He then lived an eccentric life for twelve years, getting 
syphilis, as he said, from "using an unclean handkerchief I " At the end 
of that time he had another attack of simple mania of the same general 
character as the one described, but all the symptoms more severe. He 
was more incoherent, less brilliant, less interesting, more disgustingly 
immoral — his brain, in fact, had the fine edge of all its qualities taken off. 
He died, after a few years, still maniacal, but with some of the mental 
enfeeblement of dementia. 

Such a patient must be regarded as suffering from simple mental ex- 
altation with mild excitement, the result of a hereditary instability of 
•brain. My experience is that brain-work and education tends towards 
:this condition in those predisposed. One cannot speak dogmatically, but 
I think that if such a man's brain had never been highly educated, or if 
he had not taken to intellectual work, or even if his wdfe had lived, he 
never might have developed the morbid brain elevation at all. It might 
have remained all his life, as it had done for forty -five years, a mere 
potentiality. Such cases are most difiicult to treat and manage. They 
will not be controlled outside an asylum, where they create scandal and 
waste money, yet it is for a long time impossible to certify them as insane ; 
and when sent to asylums it is undoubtedly hard on them, for they are 
sensitive and irritable, and capable of enjoying life to a large extent. 
Such attacks are usually over six months in duration, but I have seen 
two very transitory and pass away in six weeks. I do not know any 
method as yet to influence favorably such morbid energizing of the brain 



STATES OF MENTAL EXALTATION. 131 

except quiet, fresh air, non-stimulating food, warm baths at night, and 
bromide of potassium. 

The following case, of short duration, was undoubtedly benefited by 
restraint in an asylum. It was that of C. C, a member of a learned 
profession, aged fifty-nine, of a sanguine temperament, and cheerful and 
frank disposition, and good bodily health, good habits, and no hard work. 
He had been morbidly excited in mind on four or five previous occasions, 
the excitement passing off in six weeks, being treated by his being sent 
off to a lonely country place to "walk it off" among the hills. There 
was no admitted or known heredity (such facts in family histories are 
kept very secret and are soon forgotten, so that they are often really not 
known to the younger members of a family), except that his mother had 
been in a state of senile dotage for ten years before her death at a very 
advanced ao-e. Six weeks before admission he had become chano-ed in 
disposition, altered in conduct, unsettled, much elevated, always talking 
about the Turco-Servian war that was going on then, restless, sleepless, 
changed in his appetites and tastes for food, and he began to dress in an 
entirely different way from what was natural to him. In his case the 
most striking alteration was in his truthfulness. Naturally a truthful 
man, Avhen his illness began he took to telling lies by wholesale about 
everything, and for no purpose or, "motive." He was boastful to ab- 
surdity, bragging of qualities nearly the opposite to those needed in his 
profession. This human nature tendency to be very proud of things out 
of one's line — the lawyer of his medical skill, the parson of his worldly 
wisdom — you will find in an exaggerated degree in mania. He was a 
marvellous swimmer, a splendid boxer ; he would dilate Avith circum- 
stantial detail on the numbers of expert swordsmen he had overcome and 
killed, and on the pugilists he had thrashed to within an inch of their 
lives. He said he was going out to the war, and would soon be made 
the general of the Servians, and he actually purchased some appropriate 
weapons. Yet there was a little method in his madness, for he was a 
little careful about who he told those wonderful tales to, and his manner 
of telling them was not quite that of a lunatic who fully believed them. 
He drank too much, and his habits were not orderly or cleanly. An 
hour before he was taken to the Asylum he had, to some persons, of 
whom I was one, whom he thought congenial spirits, told his best stories, 
and had exhibited a mixture of extravagance, lies, boastfulness, and ob- 
scenity that quite convinced two of the company (doctors there to examine 
him) that he was very insane, and they certified him at once. From the 
way he had been talking, those who took him to the Asylum were pre- 
pared for a desperate resistance. But there was nothing of the kind. 
With a verbal protest, and a manner as meek as Moses, with no resist- 
ance and no fight at all, this wondrous pugilist Avent to the asylum. He 
collapsed at once, and his Avholc effort was to explain away his conduct, 
and apologize for his language. It seemed to act like a charm on him, 
and to restore much of his power of self-control. He again, and at once, 
assumed the speech and manner of an elderly parson — this pugilist of an 
hour before. And he never again indulged in quite such speech, or ex- 
hibited such conduct, though he dressed queerly for a few Aveeks, did not 
sleep Avell, and was elevated in his demeanor. He tried hard to attach 



132 STATES OF MENTAL EXALTATION. 

unreal meanings to his tales, and to apologize for his extravagant conduct. 
In three months he was quite well, and has kept quite well since. The 
sudden pulling of himself up by a patient on being taken to an asylum is 
often seen, both in mania and in melancholia, but it does not always last. 
The brain pace breaks out again, and sometimes far harder than before, 
because at home, perhaps before children, as much self-control as possible 
is exercised, while in an asylum a man sometimes thinks there is no ob- 
ject in exercising it, and does not do so. 

In other cases of simple mania a morbid vanity is exhibited, as in the 
following case. I have no doubt that the weak forms of normal character 
are those that are usually exaggerated in simple mania : C. D., a trades- 
man, was sent as a patient to the Royal Edinburgh Asylum, and at first 
he seemed to be merely a talkative and egotistical old gentleman. But 
it soon appeared that authorship, and poetry in particular, was his special 
weakness ; while, along with this, there was a peacock-like vanity in dress 
and demeanor that was very ludicrous. By a pompous manner, a sesqui- 
pedalian speech intended to be impressive, a combination of the juvenile 
and the Byronically poetic in dress, and a very big book always carried 
under his arm, he showed his morbid vanity. He was most touchy of 
being interrupted in his long speeches, and he tried to be very withering 
in his contempt. He used to write me a letter of fifty pages of foolscap 
in the prosiest style if he had a simple matter to bring under my notice. 
Indeed, his speeches, which he tried to inflict on me every day, used to 
try me pretty nearly up to the point of my own power of endurance, 
though I am pretty well seasoned in the art of bearing fools gladly. His 
poetry was trash, which he produced by the ream, thinking it was equal 
to Shakespeare's, and he tried to read it with due dramatic effect to the 
ladies in the drawing-room in the evenings. Yet, with all this, he was 
not incoherent. He had periods of intensified excitement, when he would 
scold. He was very thin when admitted, and his nervous and nutritive 
power and tone low, so I fed him well, gave him a liberal allowance of 
good London porter, extra milk, and cod-liver oil, and insisted on his 
being in the open air most of the day. He got fat ; and as this took 
place his foolish vanity and excitability diminished, and he grew into 
a moderately rational human being, who left the asylum with the full in- 
tention of returning to his business. But the loss of external control 
seemed like taking ofi" the governors of a steam-engine ; he got thin, 
poetic, and morbidly vain, and had to be sent to another asylum, where 
surely they did not give him as much paper as we did, for he abused the 
place most heartily, and wanted badly to come back to Morningside, but 
we had no room for him, and he died in a year or two, still insane. 

I have met with cases of simple mania where the lack of controlling 
power was seen, not so much in speech or ordinary conduct as in want 
of muscular inhibition. I had a young lady, C. E., under my care once, 
who came of a very nervous family, and whose brother's case I have 
referred to (p. 60), as exhibiting such morbid indecision and paralysis of 
volition that he could not make up his mind which stocking to put on for 
half an hour. She seemed perfectly well when one spoke to her, but 
when left alone she would make faces, jump about, tear her clothes, turn 
heels over head, scream, pick her skin, and masturbate apparently auto- 



STATES OF MENTAL EXALTATION. 133 

matically without much erotic intent or much sexual feeling. In the 
midst of all this, if one addressed her she would sit up and talk as in- 
telligently and quietly as possible. She had no delusions, no tendency 
to violence, and was gentle and lady-like. She came into the asylum as 
a voluntary patient, and declared that she could not restrain those move- 
ments. Like chorea, they came on in an aggravated way at the menstrual 
periods. They were unlike choreic movements in their real character, 
being, if one might use a contradiction in terms, automatically volitional. 
She did not sleep, and could not employ herself for any length of time. 
She recovered from the first of these attacks in a few months, but then 
had a more severe one, over which no treatment had any permanent 
effect, and she got thinner and more attenuated, and died of exhaustion 
in about tw^o years. She was free from delusions, and, in a way, intel- 
lectually sound up to the last, during the periods when she picked her- 
self up. Every sort of treatment was adopted, everything to fatten and 
improve the nerve tone that we could think of — cod-liver oil, maltine, the 
phosphates, hypophosphites, arsenic, strychnine, etc. All the usual seda- 
tives and narcotics were tried — the bromides, opium, henbane, cannabis 
indica, lupuline, camphor. She was anaesthetized by ether and chloro- 
form. She had blisters, warm baths, exercise almost to exhaustion, etc. 

That was an extreme and pure example of a symptom which we see 
commonly enough in mania,' viz., Automatic coordinated movements that 
are ordinarily voluntary, but result evidently from morbid exaltation of 
function in the highest motor centres in the convolutions. It is a mus- 
cular mania, the intellectual and volitional power being comparatively 
intact, but the highest ideo-motor inhibitory centres being paralyzed. 
It was a curious fact that her brother should have been affected in such 
a different and psychologically contrasted way — in the one, the w^ill not 
being able to put the muscles into action ; in the other, not being able to 
stop them. 

I said that simple mania assumes the form of ''moral insanity " at 
times, without apparent intellectual aberration. The system of checks 
on inclination, doing duty for its own sake, and efforts after the good, 
which by the constant strivings of years has become a habit, and consti- 
tutes the man's moral character, sometimes vanishes like the early dew 
at the beginning of an attack of mania. I shall give an example. C. F., 
a lady of good education, good morals, refined disposition, and lady-like 
tastes, had several attacks of mental disease, of which the following were 
always the symptoms : She slept much less than usual, and got thinner. 
Her expression of face changed. Instead of being a pleasant-looking 
woman, her features acquired a coarser look. She ate twice as much, 
and lost the delicate ways of a lady. She lied, stole, whored, and took 
pleasure in annoying or hurting every person she came across. She was 
cruel to animals. She was such a blister and firebrand that she could 
live in no private house with others, and in the asylum she could sot up 
ten patients in as many minutes. She had the most extraordinary in- 
stinct in finding out the weak points of her fellow-creatures I ever saw, 
and she remorselessly used this for their annoyance, tliis being her chief 
delight. She did not court a fight, but never declined one with any per- 
son whom she had roused to fury, enjoying it too ; and yet. with all this. 



134 STATES OF MEXTAL EXALTATION. 

she was plausible, always with a ready excuse for her scrapes, could make 
herself most agreeable at an evening party, and would have defied any 
doctor to find facts indicating insanity in an hour's conversation. It was 
only by watching her conduct that such facts could be got, and she could 
be certified. She was such a nuisance that asylums passed her on from 
one to the other as too troublesome to keep, though she seldom gat into 
a rage or became outwardly excited. And all this came on her at inter- 
vals like another disease, passing off, and leaving her the same refined, 
moral, and pleasant lady she had ever been. 

I had once under my care a girl, C. G., age 17, the daughter of a 
gentleman, her mother being intemperate. Had been well brought up, 
and up to within a week of her admission to the asylum, a well-con- 
ducted girl. She was of a robust and perhaps rather sensual constitu- 
tion, who, without showing any previous sign of insanity, except conduct 
that was called wayward and disobedient, left her home, wandered to 
where some v>'orkmen lived, in a lonely place many miles off, and passed 
the night with them. She showed no other signs of mania, when taken 
home, than utter disregard of her parents' feelings, bad language and 
violence to them, want of right feeling of any sort, and threats to com- 
mit suicide. Those symptoms were recognized as constituting insanity, 
and she was sent to the asylum. This state of matters passed off in a 
few days, and she became apparently well in" all respects, except that she 
seemed blunted in her feelings, incapable of applying herself to any work, 
and at times sullen and stupid. Her catamenia had been irregular, and 
she had suffered from severe headaches before the attack. She remained 
free from excitement, though not considered Avell, for about six weeks, 
when, just before menstruation, and preceded by frightful cephalalgia, 
and a day or two of dulness and mental torpor, she had an acutely 
maniacal attack of great violence, coming on like an explosion, and 
lasting for a few days. She had three of those within a month ; then 
she had in the next two months several sullen, stupid attacks. In five 
months she recovered. Each maniacal attack was accompanied by a foul 
tongue, deranged bowels, flushed face, and total loss of memory and 
power of attention. After she recovered, she had no recollection of any- 
thing that had occurred during the attack. Thus the immorality and the 
disobedience and disregard of her parents' wishes were clearly shown to 
have been sj-mptoms of an attack of simple mania which preceded the 
three acute attacks. 

I once saw a boy, C. H., of 14, whose father was a drunkard, wife- 
beater, and of a most ungovernable temper, though a clergyman, and his 
mother, a down-trodden, rather soft woman, his elder brother being just 
like the father. His father used to make C. H. drink when a mere boy, 
and taught him to smoke. When a child, he had been of a most ungov- 
ernable temper, utterh^ undisciplined and disobedient, assaulting his 
mother, swearing, shouting, breaking open locks, knocking about furni- 
ture, threatening to shoot first his sisters and then himself, buying a pistol 
and practising with it. He could not be got to go to school, or to do 
anything useful. His habits were most irregular. He would stay in 
the house for weeks at a time, and was unsocial and unplayful. When 
I saw him he was c^uiet and apparently reasonable. He was a delicate. 



STATES OF MENTAL EXALTATION. 135 

nervous-looking boy, with a restless, elevated expression of eye and face. 
When I said he would be sent to sea if he did not behave better, he re- 
plied that the man who came for him would get the contents of his 
revolver. I recommended him to go and travel with a sensible tutor, 
and this was attended with benefit to him. 

Not only are the morals affected, but the whole character is altered. 
I have seen many people improved vastly in certain respects during a 
slight attack of simple mania. I knew a naturally reserved, proud, un- 
social, rather cantankerous, selfish, stupid, miserly man become for a time 
genial, bright, good-mannered, and generous during such an attack. The 
changes in the tastes, instincts, and even in the organic appetites are 
often marked and most peculiar. Most patients do not like the same 
food as when in health. They often take to excessive smoking, and 
sometimes to drinking, independently of their habits in those respects 
when in health. The delicate likings are not only lost, but new repug- 
nances develop themselves, and former feelings of friendship are com- 
monly altered or lost. The personal habits tend to become untidy, 
slovenly, and dirty; and, by the way, this applies to melancholies as well, 
and indeed to most of the insane, if these things are not looked to and 
corrected. 

The higher intellectual tastes also change. I knew a man who could 
not appreciate, and, as a matter Of fact, neglected his favorite authors, 
taking to their exact opposites. When well, he read Gibbon and Hume ; 
when ill, he took to Burns and Swinburne. 

The sort of brain evolution into insanity at an early age, which the 
Germans have called ^'Primare Verrilcktheit," in which changes of char- 
acter, foolish insane conceits, waywardness, unreasoning extravagances, 
unsocialness, gradually develop into delusional insanity or dementia, may 
at the beginning usually be classed as simple mania. The FoUe raison- 
nante of the French corresponds in a general way to the milder cases of 
simple mania. 

Simple mania is very often the first stage of acute mania, which w^e 
are to consider next. The following letters of a young unmarried man, 
C. J., who naturally was of a modest, rather shy disposition, but who 
had for a month labored under simple mania with strong exaltation of the 
nisus generativus, and was passing into acute mania, illustrates the mental 
condition of such a person. The first two letters are elevated and delu- 
sive, but nearly coherent ; the third, a month afterwards, very much more 
extravagant. 

Edinburgh, 7th December. 
Dear Dr Clouston, — I had a good night's sleep hist night after the pleasant even- 
ing I had, and feeling sure, after the kindness I have met with here, that the best 
way of getting a perfect cure is to make a clean breast of it, I now try to do so. I 

believe that 1 am a mari-ied man, and that a lady called iNLiss -, the reputed 

daughter of , is really my wife, further that she has had children by mo, one 

of which is dead. I believe I have ten children by her still alive, three of whom I 

used to believe the children of my late uncle , who now live with his widow 

at , four who were brought up by , aiid three who were brought up by 

my reputed parents' friends — ^ . I have long had this belief, but not having any 

proof but instinct to guide me, I refrained from stating it. I believe it is true. 
Should it not be so, why, it only proves my love for her and them, and I fool suro 
you will try and cure me of the delusion. I write as one Christian to another older 
and more experienced one. — With all respect and contidonce, Youi-s . 



136 STATES OF MENTAL EXALTATION. 



^th December. 



Dear Dr Clouston, — Tn my last letter 1 put the cart before the horse. I believe 

Mr (a fellow patient) to be Duke Constantine, ni}^ father and Miss to 

be , but I am wrong there I think. Yours faithfully . 

MoRNiNGSiDE, EDINBURGH, ?,th January, 

My Dear Old , — I have at last fallen in love with the prettiest girl you 

ever saw. I got your letter, thanks, old man, and the quotations which I enjoyed, 
and went to look for it in an old coat, but couldn't find it — well but this girl you 
know I'm a bit of a student and a selfish brute, but for all that I love the girl, you 
may call a thing two names, but it's the same nearly ? 

Now the fact of the matter is they are so uncommon kind to a fellow here women 
and men, it's a fact, but then I was far far below the normal point of sanity, that 
even although I was doomed to remain here all my natural life, I could do it with 

ups and downs, but j^ou see this girl, . Were I pronounced sane enough to 

be out, she might have me. The fact is, , I'm such another uncommon agree- 
able fellow at times, but then it's the liver, as aD Irish friend of mine, that I suspect 
one may say it as a joke. Dr Clouston, who paints his face, keeps me here as a profit 

to the concern. Now this girl . If in a fortnight Clouston doesn't let me up 

to Craighouse that's the superior house where we gets tarts, but there is a very black 
hole of a boot-house yet, would you as an S.S.C., is it, or no, a writer take up my 
case as a sane man, for the girl's sane you know. I have enough to pay you. some 
£1600 I think and over, and I'll spend it all for the sake of the honor of the sex. 

The Christians here all love one another, though we fight at times like the Kilkenny 
cats, but try afterwards and bury one another's remains for the sake of the health of 
the remainder. There are a few dear little children here, pigs, and rabbits. 

I'll let 3"ou hear in a fortnight, if the powers will let the epistles pass. 

You never sent me marriage cards, — Your afiT. friend. 

P. ,S.— How's the little boy ? 

Acute Mania. — The '' raving madness " of the older authors, or acute 
mania, is perhaps the type of all insanity, both in the popular and 
professional mind. Standing thus, and being the least rational, least 
conscious, most noisy, most unmanageable, and sometimes the most dan- 
gerous variety of mental disease, it affected the conceptions and the treat- 
ment of all other varieties in a most unfavorable way. In it, many 
patients had no more " reasoning power than a wild beast," and all per- 
sons concluded to be insane (the conception of insanity was then a much 
narrower one, embracing much fewer persons), were accordingly treated 
by manacles and chains, stripes and darkness. Small compassion w^as 
felt for them, few laws protected them, little medical skill or study was 
exercised in their behalf, for they were reckoned beyond the pale of or- 
dinary humanity. Even in Esquirol's time, at the beginning of this 
century, such patients are pictured in wild contortion and fury of look and 
action, and are represented heavily bound even in his illustrations. Yet, 
this is a type of disease that is now-a-days not at all so common as others. 
Out of the twenty-three hundred and seventy -seven admissions into the 
Royal Edinburgh Asylum during the seven years 1874—80, only two 
hundred and ninety-seven, or only eight per cent., were classified as acute 
mania, and there were not twenty of these that could have sat for 
Esquirol's pictures. Acute mania may be defined as intense mental 
exaltation with great excitement, complete loss of self-control, with some- 
times absolute incoherence of speech and loss of consciousness and 
memory. After twelve months it is arbitrarily no longer reckoned acute 
but chronic mania. Some authors set up a period of forty days, during 



STATES OF MENTAL EXALTATION. 167 

which alone the disease was to be called acute mania. This had no 
foundation in any clinical fact. 

Acute mania begins in various ways. The most common is by its 
commencing as simple mania, and then passing into the acute form. But 
I have seen it begin quite suddenly, the patient being one hour a sane, 
rational, responsible being, and the next acutely maniacal. It often has a 
melancholic prelude. It sometimes begins by the patient's expressing a 
delusion out of which, as it were, the extravagances seem to arise. 
Sometimes it begins by emotional, sometimes by intellectual exaltations 
and perversions, sometimes by both. At other times, it begins by altera- 
tions of habit, appetite, and propensity. It commonly has premonitory 
symptoms, bodily and mental, such as headaches, a confused feeling in 
the head, a muscular fidgetiness, an unrest of body and mind, a feeling 
that something is going wrong or dreadful is to happen, a feeling of wild 
commotion in the head as if it were to burst, an impulsive desire to do 
something, to break glass, or do violence to those within reach. There are 
usually disturbed sleep and constant dreaming, usually of an unpleasant 
kind. I have known, the temperature rise to over 100° before even the 
patient could be said to be in any way maniacal. All those symptoms in 
a typical case are soon replaced by great restlessness and muscular agita- 
tion ; a complete change of emotional state, this often becoming very 
joyous ; a rapid and uncontrolled passing of the ideas through the mind; 
vivid kaleidoscopic mental pictures of the past ; scraps of former life and 
experience suggested by chance associations; a tendency to constant 
talking whether any one is present or not; passing from one thing to 
another and soon becoming incoherence of speech. The manner is 
utterly changed, being usually jolly or fierce. There may be ceaseless 
laughing, or scolding, or swearing. Conversations are held in loud tones 
with imaginary people whose voices are sometimes heard or their forms 
seen. Sometimes, too, there are hallucinations or perversions of smell 
and touch. The common sensibility and all the senses may be hyperies- 
thetic at first, but soon become dulled. Sometimes there is a rhythmic 
action of mental and muscular centres seen evinced by rhyming all the 
ordinary conversation, or by regular movements of the limbs and body. 
Frequently there is a tendency to shut the eyes so as to exclude the real 
impressions of the senses, and live in the false consciousness created by 
the morbid energizing of the bram. Conversations with old fidends now 
dead will be carried on. Scenes of childhood and years gone by will be 
vividly realized. The temperature is over 99°, the pulse quick and 
sometimes full, and the skin moist at this stage, the tongue getting furred, 
the appetite usually gone, the tastes and sense of decorum and decency 
perverted. At the end of this stage, the poAver of self-control may be 
utterly lost, though by rousing him the patient may by an eflbrt ]iiok 
himself up and talk and behave rationally for a few minutes. The 
memory may at this stage be good, and the patient remember afterwards 
what happened then. 

A still further stage is when the patient gets more actively excited, 
shouts, sings, attacks those about him, mistakes their identitv, calling 
them by different names, thinks they are "acting" on him, rushes about, 
and would sometimes injure himself or those near him. The tongue gets 



138 STATES OF MENTAL EXALTATION. 

more and more foul and soon dry, with sordes on the teeth and lips ; the 
appetite is not only gone, but there is a strong revulsion against food, so 
that forcible feeding has to be resorted to. The speech becomes absolutely 
incoherent, and there is no consciousness, memory, power of attention, or 
any care for the calls of nature. This is the "delirious mania" of some 
authors. 

The degree to which there is remembrance afterwards of the events 
occurring during acute mania differs greatly in different cases. The 
friends of patients will usually be most anxious on this point, fearing the 
effect, when recovery has taken place, of the recollection of being taken 
to the asylum, of being fed, etc. I advise you to be careful in predicting 
on this point. In some cases the whole period of the disease is a com- 
plete blank afterwards ; in others, things heard, seen, and experienced, 
during almost the delirious period, are remembered afterwards in a sort 
of distorted, exaggerated way. Patients often remember and complain of 
the restraint and the force needed to overcome their violence, the com- 
pulsory walking, dressing, and feeding, but have no recollection of their 
own condition at the time which made all these things necessary. I think 
that the memory of events during the disease is regulated by the degree 
in which the power of attention is unaffected. In health you know how 
much memory depends on attention, which, like a muscular act, implies 
much fatigue in its prolonged exercise. There may be a presentation of 
an object to the eye, or a sound to the ear, yet if there is no attention 
there is no brain registration, and no after-power of representation or 
conscious memory. The late Professor Laycock's^ views in regard to 
memory, organic or inherited, in regard to synesis or the registration of an 
impression, in regard to the recollection, or the act of calling up the 
impression to consciousness afterwards, are very im^^ortant in our study 
of the clinical symptoms of mania. The ravings of a maniacal patient 
are often well worthy of study, both as a medico-psychological problem, 
as affording an insight into the man's mental history and constitution, and 
as a symptom of much practical import to the physician. There is no 
such thing as real "incoherence." The words and the ideas always 
cohere by some bond or other. They always relate to former perceptions, 
thoughts, and experiences, that have been registered in the brain tissue. 
Those are represented to the altered consciousness in quick succession by 
chance, not real association. 

A careful study will often succeed in discovering the association of even 
the most apparently incoherent ideas. The ideas have had some former 
connection in the consciousness of the patient. They come with great 
vividness, so that memories — representations — are taken for actual pre- 
sentations to the senses. I had a maniacal patient w^ho had kept dogs, 
and their mental images were evidently as strong as the real sight of the 
animals before his eyes had ever been. He called them by their names, 
pointing to where they stood, talked to them, and heard them barking. 
His reasoning power being perverted, he could not correct those impressions, 
and he believed the cerebral images of his former presentations to be 

1 Journal of Mental Science, August, 1875 — "Some Organic Laws of Personal and 
Ancestral Memory." 



STATES OF MENTAL EXALTATION. 139 

present realities. We may either suppose that, through morbid activity in 
the nutrition and energizing of the centres of sensation, those molecular 
changes which each previous perception had left are rendered more vivid 
and more like the original, as when a photograph by the stereoscope is 
made to look real and solid; or that through failure in the comparing and 
judging power of the brain, those faint images, which we in health call 
memories, are actually mistaken for real perceptions of real impressions 
on the senses, just as when in a dim light and dreamy humor the pictures 
on the wall stand out as real men and women. In insanity those false 
beliefs in sense impressions are called hallucinations, to distinguish them 
from insane delusions, which are false beliefs of a more abstract kind. If 
a man of fifty believes that he fought at Trafalgar, it is a delusion ; if he 
believes that he sees before him Nelson looking through his glass, that is 
a hallucination. There is a false belief of an intermediate kind^ to which 
the term illusion has been applied by some authors, but this term will 
have to be given up in this sense now that Mr. Sully has written his 
book on Illusions used in a different meaning.-^ In the sense I refer to, 
if the person really saw a man before him and said that he was Nelson, it 
would have been an illusion ; there being a real sense impression, but this 
being misinterpreted into something quite different from what it really was. 
Certain cases of acute mania are greatly characterized by the prevalence 
of hallucinations of different sensed. All those symptoms most of us now 
believe to be in some measure explained by the theory of the morbid exci- 
tation of Ferrier's and Hitzig's localized centres in the cortex of the 
brain, those centres where the impressions from the senses are received, 
and where coordinated motions arise. As further progress in brain 
physiology is made, no doubt we shall be able to localize in the brain the 
causes of perverted mentalization of different kinds. 

As illustrating extreme incoherence, I give a small bit of a "letter" 
of twenty pages, containing a string of fourteen thousand words, almost 
all adjectives and nouns, with no more connection or aim than those in 
this specimen : " Mediterranean, horses, anathematized, Athanasius, propa- 
gated, emphatic, monasteries, diocese, Egypt, hermit, biographer, abuse, 
furor, fury, medium, policies, police, hobby, sacred, phrase, administration, 
ministerial, monasticism, . . . counsel, conviction, revelation, mode- 
rate, junior, transact, absurd, disinherit, repudiate, maternal, instinct, 
claimant, reiterate, clever, rumor, demurred, finesse, illusion, abstruse." 
Now you see that there is a sort of association of ideas between a great 
number of these words, and you can imagine how one arising before the 
mental vision would suggest the one next it. Here is another letter from 
C. K., of a more usual kind of half incoherence : " Dear Durham's 
Alia, You will please see that Eliza and Bella are out. Mr Swan (his 
attendant) is to give you this in a few minutes. Compts. to Victoria 
and my mother Qiieon Elizabeth. I am putting ' John' before tlolin 
Addison, as I think him entitled to it. No kilts my bonnie Durham. 
My 'charm of life.' More than India's goods to me. Blessing on my 
bonnie wife. I Avill love you till the day I die. Compts. to Louise 

^ Illusions, by James Sully. 



140 STATES OF MEXTAL EXALTATIOX. 

and darling Beatrice. Jane Shore, and Elizabeth. Come into the 
garden, ^laud. 

** The tear fell gently from her eve, 

"When last we parted on the shore ; 
Mt hosom heaves with many a sigh, 

To think I ne'er should see her more. 
*^eep not. my love," I trembling said; 

' Doubt not a constant heart like mine ; 
I ne"er can find a prettier maid 

Whose charms can fill this heart of mine.' 
' Go. then,' she said, ' and let my constant mind 

Oft think of her you leave in tears behind.' 
'Dear maid, my heart's embrace, my wish shall be. 

The anchor's weighed! The anchor's weighed ! 

Eemember me.' -' ' 

There is no difficultT in seeing the association of ideas, or the verbal 
or alliterative suggestions running through this ''incoherence." A 
rhyming speech, or a poetical way of putting things, so very common, 
can be seen in the above letter. 

The affective condition in this, as in every variety of mania, is one 
of perversion or paralysis. We would describe the condition in most 
instances by saying that those dearest to a man are most disliked ; those 
most trusted are the objects of suspicion; those most intimately asso- 
ciated with the patient are most shunned. It is this which, more than 
anything else, makes its occurrence such a terrible calamity. Conjugal 
affection is most and first apt to give way; and it is a very common fact 
that where we have j^i'olonged and incurable insanity, the conjugal affec- 
tion of the sane husband or wife in most instances ceases long before 
the maternal or sisterly affection of the sane blood-relations. A shrewd 
old Morningside head attendant, of an observant, if somewhat cynical, 
turn of mind, was the first to point this out to me in regard to those 
who came to visit the chronic patients in the asylum. He said he 
noticed that wives and husbands were the first to diminish the frequency 
of their visits, and soon came veiy seldom, then brothers and sisters, 
then fathers, and, last of all, mothers and old aunts, who never ceased 
to come, however uninteresting the patient might be, however long he 
was insane. Xo rebuffs from the patient would discourage them ; no 
want of reciprocity would cool their love and interest, which never failed. 
I commend this observation to students of the affections. 

The actions of patients laboring under acute mania differ as much 
as their speech. They can all be referred to the morbid excitation of 
the motor and the ideo-motor centres in the brain. One man is simply 
restless, another shouts, another sings, another rushes about wildly, 
another attacks those near him, this being usually the result of delusions 
that they are going to injure him. Some violence on slight or merely 
imaginary provocation towards those nearest and dearest to them is 
common. In Plate II. (the fac-simile of a patient's letter), there are seen 
incoherence, rapid change of ideas, and hallucinations of sight. Some- 
times the patient would injure himself in his wild fury by dashing him- 
self against walls, through windows, etc. But it is surprising how 
much more rarely than is usually supposed maniacal patients are really 



PLATE II, 








U^^ ■■""•^^ -^^^ /louO^ 



^_ 



^ ^ 
















STATES OF MENTAL EXALTATION. 141 

or to any extent very dangerous, either to themselves or others. In 
this matter, old opinions and prejudices, the fact that a few patients 
are dangerous, or that a dangerous stage occurs in some few cases, have 
given a wrong general impression, and done very much harm in the 
treatment of acute mania. But we are slowly getting over this, for 
now we endeavor to assume that any patient laboring under this disease 
is not dangerous till he is proved to be so, instead of the opposite old 
maxim, that he was to be regarded as dangerous till he proved himself 
to be safe, which had this unfortunate result, that the restraints and 
restrictions and supposed safeguards imposed on him so irritated him 
that, if he was not dangerous at first, he was probably made so by 
them. No safe outlet was provided for his morbid motor energy, so 
that, like all pent-up force finding no outlet, it became dangerous, and 
often killed the patients. 

The motions and gesticulations of an acutely maniacal patient are 
often in an exact degree the muscular equivalents of the ideas and emo- 
tions passing through his brain, just as they are in the case of a savage 
or a born orator w^hen he makes a speech about a subject which excites 
him. The most awkward of men often becomes easy in his motions 
when maniacal. The expression of the face is always changed, and 
also the appearance and expression of the eyes. Usually the man is so 
changed that he looks a different man. He is always "worn-looking," 
and this is more particularly the case in the female sex. There is no 
natural beauty of face that will continue during acute mania. Usually 
the face is flushed; the skin muddy and less delicate in tint and texture; 
the features unpleasant to look on. As might be expected, the infinitely 
delicate coordinations and fixations of the small muscular strands, that 
in the face mirror forth and express the mental and emotional states, are, 
in this disease, inharmonious, and express instead the incoordinated 
mental acts. The eyes are more especially characteristic. They usually 
glisten somewhat, as in fever; the eyelids are more widely dilated, so 
that the white is seen round the cornea; and their expression is that of 
excitement and turmoil. 

The whole digestive tract is affected more or less. The secretions of 
the mouth and the saliva are altered in character, and, when inoculated, 
produce a septic or irritating influence. The sores resulting from a bite 
of such a patient, as I have often seen in attendants, are apt to be angry, 
the inflammation running up the lymphatics. The most recent investi- 
gations show the septic character of the saliva. The tongue is usually 
furred, and the breath foul. When the condition becomes delirious, 
there is always a tendency to have a dry mouth and tongue, with sordes 
on the teeth. The appetite for food is usually paralyzed, though not 
ahvays that for drink. The digestion is often vigorous enough, though 
not in the exhausted stage. I have found the stomach full of undigested 
food in patients who had died of exhaustion from acute mania. The 
bowels tend to be costive, though this is not always so. The tempera- 
ture is usually from one to two degrees above the normal, especially the 
evening temperature. As we shall see, it runs far above this souu^times: 
but if it rise much above 100°, we look out for a febrile or inilaunnatory 
cause, or for general paralysis, or for organic disease. The skin is 



142 STATES OF MENTAL EXALTATION. 

usually clammy and ill-smelling, though sometimes harsh and dry. In 
women, the menstrual function is almost always interfered with, being 
usually stopped after the excitement has continued for a few weeks. 
The odor from a woman both menstruating and maniacal is most offen- 
sive. I find that out of the last fifty women admitted to the Asylum 
laboring under acute mania, three-fourths had irregular menstruation, 
and in most it ceased till they became convalescent or demented. The 
common sensibility is much diminished in such cases, patients not feeling 
pain acutely, some not feeling it at all. Injuries, cuts, boils, Avhitlows, 
and such painful affections are borne without any complaint of pain. 
With their feet inflamed, they will walk — with their hands in sores, they 
will use them freely. 

The continuance of this condition is, of course, attended with rapid 
and great loss of body weight. I have known a patient lose a stone of 
flesh in a week, notwithstanding that he was getting plenty of food. 
But after losing any redundancy of fact, it commonly happens that the 
intensity of the disease diminishes, and the loss of weight is less rapid. 
It usually takes a considerable time, always provided a suflicient quan- 
tity of proper food is given, and proper treatment adopted, before ex- 
treme emaciation and weakness result. The more intense the attack, the 
shorter is usually its duration; in fact, a great prolongation of very 
acute delirious mania with a temperature of 100°, no sleep, and con- 
stant violent motor excitement are inconsistent with life. Few cases die 
in the first week of the attack ; some do in the first fortnight, and some 
in the first month. In a somewhat subacute form, it is wonderful how 
long it may last, without producing fatal results, or even reducing the 
patient very much, if he eats enough — and enough may mean four times 
his usual amount of food — and is sufiiciently in the fresh air, and is not 
restrained in his movements. In by far the majority of instances, such 
mechanical restraint as used to be employed in this country, and is still 
employed elsewhere, by strait-jackets, gloves, straps, etc., causes such a 
feeling of degradation, irritation, and resistiveness, that the good effect of 
any actual conservation of force by restraint is in my opinion far more 
than counterbalanced. The disease, if it does not kill, is more apt to 
run on into chronic mania and deuientia. To restrain the mere outward 
muscular movements, while the motor energy is all the while being 
generated in the brain convolutions, is eminently unphysiological. Almost 
as well restrain the movements of the choreic or the convulsions of the 
tetanic patient by binding them tightly, and expect a good result. Our 
great efforts in the treatment of such cases now are to find suitable 
outlets for the morbid motor energy, to turn the restless, purposeless 
movements into natural channels, to get the patients to dig, and wheel 
barrows soon, and to walk long distances, instead of shouting and ges- 
ticulating. We find that this saps and exhausts the morbid energy and 
excitement, producing healthy exhaustion and sound sleep, vigorous 
digestion, and healthy excitation of the skin, the glands, and the excre- 
tory apparatus generally. This is the chief physiology and philosophy 
of the modern British non-restraint treatment of mental diseases. No 
doubt there are exceptions to all rules. I have seen cases where re- 
straint had to be applied to prevent the patient exhausting or hurting 



STATES OF MENTAL EXALTATION. 143 

himself, but they are amazingly few in a well-equipped asylum, with 
large grounds, a farm, good attendants, and plenty of them, and a 
padded room. Under those circumstances, not one case in ten thou- 
sand is found to need restraint. But it is quite different when we 
have to treat a patient in a private house, or with insufficient attend- 
ance. Then mechanical restraint may be quite unavoidable. It often 
happens that, at the commencement of a case, where the symptoms have 
developed rapidly into an acute form, you may think it advisable to give 
the patient a chance of its soon passing off, or arrangements cannot be 
at once made for removal to an asylum through the absence of those 
who can authorize it, or the relations of the patient may absolutely insist 
on his being treated out of an asylum. In all these circumstances, you 
have to do the best jon can with the means at your disposal, carrying 
out to as great an extent as you can the principle of providing an outlet 
in the open air for the morbid motor energy that is being generated in 
the brain convolutions, but using, it may be, restraint to some extent. 

Acute mania may in most cases be divided into three stages : the first 
that which I have described as simple mania; the second, that of ordi- 
nary acute mania ; and the third, that of delirious mania, Avith a ten- 
dency to dry tongue, etc. The third, under proper treatment of the 
first two stages, does not occur in many of the patients. 

As you can readily understand, from the delicate constitution of the 
gray brain- substance — that highest evolution in nature of combined func- 
tion and structure — and the infinite complexity of its balanced and 
interdependent functions, the continuance of such an abnormal storm as 
that which exists in acute mania is very apt to be followed by permanent 
and irretrievable damage. Such a storm, besides all the bodily symp- 
toms and disturbances which I have described, is accompanied by intense 
congestion and over-action in the gray neurine and brain generally — the 
former usually seen in limited areas (see Plate III.), which tends soon 
to pass into structural changes. The cells soon get granular; there is a 
proliferation of the nuclei of the neuroglia; the lymphatic spaces and 
perivascular canals soon get over-dilated and blocked up with debris, and 
an enormous number of microscopic capillary extravasations take place 
in and around the convolutions in bad cases. Even the coverings of the 
brain are affected, the vessels getting thickened in their coats and tor- 
tuous, the fibrous matter of the pia mater getting hypertrophied, the 
arachnoid milky, the dura mater thickened or adherent to the bone, and 
even the bony case becoming dense and thickened. 

All those things happen through prolongation of the acute symptoms. 
Therefore, it is of the last importance to shorten, if we can, the acute 
stage. Every week of this adds to the chances of the acutely excited 
state being followed by more or less permanent mental defect. Even the 
present risk to life is not so grave a risk as that; for which of us, if we 
had the choice, would not prefer, on the whole, death to a degradation 
from our mental and emotional eminence in creation to a state of per- 
manent mindlessness, in which we Avould be dead to the love and hatred 
and to the joys and pains of life, oblivious of the past, and unconcerned 
for the future; stirred by no ambition; capable of no efibrt, and un- 
moved by any motive ? For such is dementia, of which I aui to speak 



144 STATES OF MEXTAL EXALTATION. 

aftenyards, that follows and results from mania. About sixty per cent, 
of the cases of acute mania recover, seven and a half per cent, die, and 
thirty -two and a half per cent, become demented, or pass into chronic 
mania. There is, perhaps, more opportunity for right treatment and 
management in acute mania than in any other kind of mental disease. 

Gexeral Ixdicatioxs for THE Treatment of Acute Mania. — In 
the beginning of the attack, and sometimes, when the patient is wealthy, 
all through it, we have to treat the case at home. Now, no doubt, the first 
thing to be done is to get properly trained attendants — one, two, three, 
or even four may be necessary for night and day work. Patient, sen- 
sible, experienced, cool and kindly men or women are what we want. 
Then proper arrangements must be made, a good suite of two large 
rooms on the ground floor of a house, with a garden, and not too near a 
public road, being required. Small breakable articles must be removed, 
but do not make the rooms quite desolate or unattractive looking. Fasten 
windows not to open more than five or six inches, and see that no knives 
or lethal weapons are too handy. But do not do all this demonstratively 
to attract the patient's attention. Next, you must look to the feeding 
wdth suitable nutriment very often : sometimes you can give it only little 
and often; sometimes in ordinary meals, with beef-tea and milk in 
between. Milk, eggs, beef-tea, ground beef, custards, strong soups, with 
plenty of vegetables, and porridge are the best, as often as the patient 
can be got to take them, and in as large quantity. Do not for a moment 
be afraid of a dirty tongue, and think it contraindicates food. Nothing 
could be a greater mistake, in acute mania at all events. The furred 
tongue is not from an overloaded alimentary canal, but results from per- 
verted innervation of the digestive tract. Malt liquors, such as porter 
and ale, can be given freely w^th advantage — good wines, too, if they 
can be got. Even whiskey or brandy will act as a direct sedative to the 
excitement in some cases. Anstie taught us some good therapeutics, in 
his Stimulants and Narcotics^ on this point. But alcohol, you Avill 
find, will sometimes flush and cause excitement. In that case, use it 
sparingly. I have seen a pint of beef-tea representing all that was 
soluble in a pound of beef-steak and a glass of whiskey reduce the tem- 
perature 2-3°. To show the quantity of food that such patients can 
take and digest, I mention that at the asylum I am never satisfied except 
the bad cases get at least six eggs a day beaten up in liquid custards, in 
addition to their ordinary food, beef-tea, etc. I have known many pa- 
tients take a dozen eggs a day for three months running. The constant 
motion and fresh air enable them to digest and assimilate all this. So 
long as a patient is losing weight, the physician should never be satis- 
fied. When he becomes stationary, then one may begin to think that 
the disease is being overcome by nature and treatment. When he begins 
to gain in weight, and the temperature becomes normal, then con- 
valescence or dementia has begun. The patient should be weighed every 
week during the acute stage. 

Next to good food and nursing, fresh air is most essential in treating 
a case. No patient must, on any account, or in any weather, except he 
is excessively run down indeed, be kept in bed or in the house. Herein 
is the essential difi"erence between the treatment of this disease and that 



STATES OF MENTAL EXALTATION. 145 

of acute bodily complaints. I often keep patients out all day in the 
summer-time. When they are getting better, they all say that they 
feel better out than in. There is no soporific, no calmative, and no 
digestive like the fresh air. And the attendants must not restrain or 
interfere more than is necessary. There should be no nagging and 
small interferences, and no arguing, but a kindly, firm mode of dealing 
with a patient — coaxing, when coaxing will do, and 'firm insistance and 
force sufiicient to overcome resistance when necessary. There is a certain 
kind of tact which some people have, and which may be partly acquired, 
but which is often a natural gift, and, when present, is of the greatest 
avail in overcoming resistance, persuading patients to take food, etc. 
Women have it more frequently than men, and women will often 
persuade male patients when their own sex fails. It does not do to let 
patients have too much of their own way. A happy mean between that 
and too much interference should be pursued. It is better to be honest, 
and not deceive patients into doing things. That often makes them lose 
confidence, and does harm afterwards. Medicine when given should, as a 
general rule, be given as medicine, and not be put in food surreptitiously. 
The safety of the patient and those about him must of course be pro- 
vided for. 

For the bowels it is sometimes necessary at first to use laxatives and 
enemata, and even strong purgatiVes, such as croton oil, but I try first 
such mild medicines as castor oil, Tamar Indien lozenge, liquorice powder, 
warm water enemata, etc. Do not insist on a stool every day ; one every 
second or third day is quite enough. Depleting remedies of all sorts are 
in my opinion bad. 

There is one remedy that I have seen do good in many cases, and in a 
few act like a charm, and that is, prolonged warm baths with cold to the 
head. The effect of this is to fill the capillaries all through the body, 
and to withdraw blood from the brain, to depress the heart's action, — and 
hence its danger, — to soothe the nervous irritation, and to produce sleep. 
I have the highest opinion of its efficacy, but unfoi'tunately it is attended 
with danger in some cases. A man, whom I could not detect to have 
heart disease, once died in my hands, as it were, when I was sittino; 
beside him, after being less than an hour in water at 103°. I know of 
two other cases where syncope and death resulted in the same way. I 
used to keep the water up to 110°, but I never do so now. In fiict, 
I now prefer 99° as the proper temperature. But the eftect with this is 
not so quick or so marked. Baillarger used to keep his patients steeping 
for days in water at 96° or 98°. I do not think, however, the treatment 
is so much in vogue now in Paris as it was twenty years ago. Shower- 
baths of a mild kind are sometimes useful when the mania threatens to 
become chronic, or when the earlier symptoms of dementia show them- 
selves, and the patient is strong and can react after the bath. The great 
trouble is that patients are apt to look on the shower-bath in any form as 
a punishment, and so its use may have a bad moral effect on them. 

One difficulty in treatment is to use narcotics and hypnotics rightlv. 
The greatest differences of opinion have existed, and do prevail at present, 
about them. What we want and have not yet got is a medicine that will 
cause really natural, restful, refreshing sleep. Then we Avant a nioilicine 

lo' 



146 STATES OF MENTAL EXALTATION. 

that Avill stay or slacken the morbid energizing of the brain cells in the 
convolutions without affecting the appetite or the nutrition. That, how- 
ever, is not known to us in a perfect form. All medicines that tend to 
lessen the appetite or impair the digestion or nutrition, I condemn 
utterly in this disease. In ninety -nine cases out of a hundred opium 
does this, and should not be employed except as a mere temporary 
placebo or for a special purpose. My experiments with it. and practical 
experience of it is, that it has those objectionable effects in most cases 
where given. 

Chloral we all believed in, and used most extensively in mania after 
its discovery. It seemed a perfect sleep-producer, [lumbers of cases 
have I kept under its influence day and night for weeks, and many of 
them certainly got well. But I do not believe so much in it noAv. Its 
sleep is sound and seems natural, but somehow is not refreshing like 
nature's sleep. I am inclined to think that one or two hours' sleep 
naturally after a day's exercise in the open air is more than equal to eight 
houi's' chloral sleep. My experience is that it has a subtile influence for 
harm on the brain when much given, by which the organ loses that 
quality which we call tone. The patients cannot bear pain so well. 
They have not the resistive power, and they are apt to look pale and unre- 
freshed in the morning. Besides this, I had two patients who died 
suddenly, each of them during a sudden gust of excitement when under 
the influence of moderate doses of thirty grains ; in both of them I found 
the blood dark and fluid, and the right side of the heart and the lungs 
engorged, as if there had been a sudden paralysis of the breathing centre 
in the pons. I could not certainly say that the chloral caused their 
death. One had decided brain disease, and sudden deaths do occur in 
acute mania when no medicine has been given, through, as I believe, epi- 
leptiform conditions causing paralysis of the breathing centre. I have 
jiever given so much chloral, especially as a sedative during the day, 
since. xS ow I give it at night, or after, or during convulsions, and 
.always in small doses of from ten to twenty-five grains, with from half a 
-drachm to a drachm of bromide of potassium. 

A combination that I have found most useful has been the bromide of 
potassium and tincture of cannabis indica, with which I have made 
careful and prolonged experiments. It soothes during the day, and some- 
times permanently allays the brain excitation, and it causes sleep at 
night, without diminishing the appetite much or impairing the digestion. 
I have used the bromide alone in acute mania extensively and experi- 
Tuentally. In small doses it seems to have no effect. In very large and 
continuous doses, say a drachm every three hours continued for many 
days, it will cause bromism, and quiet the patient, but Avhen its influence 
is over he becomes as bad as ever. I have never seen any medicine, 
where the maniacal excitement and the physiological brain-torpor of the 
drug seemed so visibly to fiorht for the masterv. Hvoscvamine is an 
admirable quieter of motor restlessness, and often does no harm, but I 
have seen dangerous coma produced by it, and its subjective effects on the 
patients must be disagreeable, for they dislike it extremely. I have seen 
nitrite of amyl (a drop inhaled) produce calm in a suddenly epileptifonn 
case of mania. Morphia and hyoscyamine may be subcutaneously 



STATES OF MENTAL EXALTATION. 147 

injected if refused by the mouth, but I advise you to beware, and not 
use too large doses in this way. It may be justifiable in treating cases at 
home to tide over severe paroxysms with those drugs, and sometimes to 
keep the patient out of an asylum as long as possible. When a maniacal 
patient is sent to the asylum, I now frequently use for a few nights small 
doses of the bromides and chloral, and give warm baths ; but after a fort- 
night, when I see that the attack is not going to be cut short or run a 
very short course, I trust to the nursing, diet, and conditions of life I 
have mentioned, with continuous tonics. Conium is a good sedative in 
some cases, and tincture of lupuline, in the milder cases, I have known 
to produce sleep. Camphor in some women does much good. 

I now give nearly all my cases quinine from the beginning, adding 
iron in some cases that are manifestly annemic, with sometimes the phos- 
phates of lime and soda. The bitter tonic and digestive medicines I use 
largely in cases that run on for long, and during convalescence. 
Strychnine is most useful at the stages of the disease where there is 
a tendency to stupor and brain-torpor. 

When the acute symptoms pass off, especially if they have lasted long, 
there is apt to be a stage of reaction, attended, in some cases, with com- 
plete prostration, in others with depression, in others with an apparent 
mental enfeeblement which most (jlosely resembles dementia ; in fact, it 
is a dementia or stupor of a transitory kind. You must on no account 
confuse it with the real dementia, for while the one is quite amenable to 
treatment, and requires treatment urgently, the other is an incurable 
brain condition. I once myself showed a girl, who had just passed 
through a prolonged attack of acute mania, and who was stupid, dirty in 
habits, and demented, used her as a typical example of newly begun de- 
mentia in a clinical lecture, and pronounced her a hopelessly incurable 
case; but she gradually picked up in flesh, got enormously fat, and her 
brain roused itself into almost its former activity, and she was discharged 
recovered. The treatment for this stage of acute mania is tonic and 
nerve stimulant, stimulating medically and fattening dietetically (use beef 
and animal food at this stage as much as possible). Rousing and occu- 
pation, and " cheering up " by amusements, etc., are most useful, too, as 
brain stimulants and restorers. Sometimes patients have to leave the 
asylum to get cured of this sequela of mania. Their brains need to be 
subjected to the natural stimuli and interests of outside natural life. 
There is a process of reeducation of their damaged but recuperatino; 
brains that must be gone through. They are in the state of a joint dam- 
aged by an acute rheumatic inflammation, that may take a long time and 
much care and treatment to get it working as it once did. As I shall 
point out, certain mental peculiarities remain permanently in many 
cases. 

Tlie following was a typical case of acute mania, running through its 
three stages both in its onset and as it passed away. The intensity of 
the brain exaltation was so great at the acme as almost to kill the pa- 
tient : 

C. L., get. 36. Married. Temperament sanguine. Diathesis ner- 
vous. Disposition cheerful, frank, and exceedingly enthusiastic when he 
took anything up. Habits very steady, and almost over-industrious, for 



148 STATES OF MENTAL EXALTATION. 

after his work was done lie would spend all his evenings in doing church 
work. Education fair. Father died at seventy, of paralysis ; brother 
had an attack of acute mania at twenty seven from over-brain-work, from 
which he re30vered, and then again had another attack, and died in it. 
Mother had an attack of puerperal mania after the birth of one of her 
children, and her maternal grandfather and aunt were insane. This is 
the first attack, and has assumed an acute form for three days. He be- 
came depressed, reserved, and altered three or four weeks ago, and this 
was accompanied by thinness and slee|)lessness. Then he began to be 
excited, elevated, talkative, and restless, and quickly passed into wild 
delirious excitement, w^hich had existed for two days before admission. 
He was most dangerous to his wife and children. He had taken little 
food for two days, and never slept during that time, though he seems to 
have had enormous doses of morphia. 

On admission he was very exalted, singing hymns, quoting passages 
of Scripture, and swearing in the same breath ; shouting and raving. 
His excitement was intense. He threw himself about the padded room, 
into which we had to put him. It took four or five strong men to man- 
age him safely, though he was a small man. He had hallucinations of 
sight and hearing. He was thin and sallow. He was covered with 
bruises, and one rib was broken, all got in his struggles at home. His 
tongue was clean and dry, bowels costive, appetite gone. Pulse difiicult 
to count, on account of his excitement. Temperature 99° on admission, 
and 100.6° at night. He felt no pain ; his motions were incessant and 
most severe. He would put his feet up on the walls, with his head down, 
and run so round the room. He would leap up and fall down. He 
would seize those near to him, and try to throttle them, thinking they 
were devils. He tore his blankets and bedding. At times he would be 
quiet, and in a way rational, then he would get maniacal in a moment 
without warning and without cause. He was fed regularly with custards 
and sherry by force, as he had a great aversion to food, saying it w^as 
poison. Patients who are maniacal, often have this delusion, the idea 
being suggested to them by their own perversion of the sense of taste. 
I have no doubt that all food tastes ill to them. This brain condition 
exhausted him very much, so that I feared he was going to die. Getting 
twelve eggs a day for the first fortnight, yet he made little progress. 
We could only get him into the fresh air for a short time each day, his 
struggles, and the risk of injuring himself, being so great. His tempera- 
ture at this time was about 99° in the morning and 100°. at night, and 
he almost never slept. Soon he began to improve, and his lucid inter- 
vals began to be more clear and frequent. He had several boils on his 
arms and legs at the time, and I looked on this as a critical event. His 
temperature never rose so high after this, his appetite returned, and we 
were able to give him solid food in a mixed form for the first time. He 
was able to walk round the grounds in four weeks, being then talkative, 
lively, chaffing everybody he met, full of fleeting delusions, especially as 
to the identity of those near him. He took most violent antipathies to 
his attendants, and would accuse them of quite impossible cruelties to 
him, such as putting him into a mill and breaking every bone in his 
body, so that we had to be constantly changing them to soothe him. He 



STATES OF MENTAL EXALTATION. 149 

was weak, pale, thin, and haggard, but said he felt strong, when he began 
to go out to walk. After that he was never in the house, except at night. 
He walked, and when tired he sat or lay down on seats in the grounds. 
He continued excited, noisy, singing, and most exalted in feeling, from 
the second month of his stay, still taking his twelve eggs a day, in addi- 
tion to his ordinary diet and other extras, and he gained a stone the 
second month of his residence. He had several short relapses for a few 
days. In two and a half months he began to have a glimmering con- 
sciousness of his position, and a faint return of natural feeling. His 
j&rst letter to his wife at that time was a model of conciseness : '' Dear 
Wife, Where are you ? C. L." 

In three months he was in the condition I have described as typical in 
simple mania — gay, humorous, careless, talkative, but with no delusions, 
sleeping well, and rapidly gaining in weight and strength. He was all 
this time getting all sorts of tonics, quinine, iron, phosphates, cod-liver 
oil, etc. This state lasted over three months, all this time his brain get- 
ting more normal in its working, and at the end of six months from his 
admission he was discharged well in mind and stouter than he had ever 
been in his life, having gained two stones in weight since admission. I 
never believe in the perfection of a recovery from acute mania, unless 
the patient is fat ; and when he is so, I always think his chances of not 
having a relapse for some time are good. I like a gradual steady recov- 
ery, too, not perhaps so long as this, rather better on the whole than a 
sudden recovery. 

The following is another characteristic case of acute mania running 
through a typical course: 

C. N., set. 47, of a sanguine temperament, cheerful and frank disposi- 
tion, and industrious and temperate habits, but of a very fiery and un- 
governable temper. This was her first attack. Her mother was insane. 
This heredity and the nearness of the climacteric period may be consid- 
ered as the predisposing causes, while the exciting cause Avas exhaustion 
from want of sleep, and mental anxiety in nursing her mother on her 
deathbed. The first mental symptoms occurred about fourteen days 
before admission in the shape of restlessness, unsettledness, and getting 
up in the middle of the night to wash. For four days she had been 
worse, seeing visions, constantly talking, imagining that people were 
under her bed, and never sleeping. On admission there were great exal- 
tation, incessant and almost incoherent talking, much excitement, walking 
about, gesticulation, singing, saying she saw the "heads of people" 
about her. She addressed the people about her, whom she had never 
seen before, as her friends, mistakino- their identity, makinir sarcastical 
remarks about them — " Oh ! Kitty, is that you ? That's a fine gOAvn 
you have on. Who gave you it? Is it paid for? " etc., etc. At times 
she was quite incoherent. In person she was fat, weighing eleven stone 
six pounds. Her organs were healthy, except that her tongue was much 
furred, and her boAvels were costive. Pulse 112 ; tem]HM-ature 90.0°. 
Soon after admission she suddenly, in obedience to a delusion, took up a 
chair and threw it at one attendant, while she seized another by the hair 
and hurt her considerably, screaming out and saying they were going to 
murder her, and that there were devils in the room. She refused to take 



150 STATES OF MEXTAL EXALTATION. 

food at first, saying it Tvas poisoned. She had to be secluded in a bed- 
room, where she would sometimes shout and gesticulate and make 
speeches, and carry on conversations with imaginary persons; then she 
w^ould lie flat on her back on the floor, keeping her eyes tightly shut, 
smiling, and never speaking at all or answering questions, evidently 
living in her morbid imaginations, and trying to exclude external sensa- 
tions. She did not sleep, and was noisy all night till the third night, 
when she slept two hours. On the first day she was so violent, and so 
strong, and so resistive, that it was thought desirable not to dress her or 
send her out. She was got into a warm bath with great difiiculty. Her 
temperature rose to 100°. It was the fourth day before she began to 
take more food than a little milk, or before we could get her dressed and 
out in the open air much. Her bowels had been costive till then, as she 
could not be got to take any medicine. She then had croton oil given 
her and an enema, and had a free evacuation of most oifensive feces. 
Her breath had been very foul. On the sixth day, though she was drink- 
ing a good deal of milk and custards, her tongue and mouth got dry and 
cracked, her pulse weak, and she showed signs of exhaustion. She was 
put on four glasses of wine, and still kept out in the fresh air, while a 
little milk was given her every half hour. She was very excited, noisy, 
destructive, and absolutely delirious and incoherent. On the tenth day 
the excitement began to abate, her tongue and mouth became moist ; she 
became more manageable, and got a good night's sleep for the first time. 
In a month from the time of her admission she had lost twenty-four 
pounds in weight, but then the acuteness of the brain exaltation passed 
off". She had ''a good day and a bad one," could sit down to meals, and 
eat her food. She could walk about, looking moderately sane to any one 
at a little distance. She could answer simple questions correctly. She 
began to have doubts as to a delusion about my being her husband, say- 
ing, in answer to my question as to who I was — "You're John , at 

least you look like him; but I'm thinkin' you're no him." She made a 
perfect recovery in four months. 

The following is a case of acute mania coming on in an hour, with 
great intensity, and gradual, but not complete recovery in three months. 
Relapse after three and a half years, attack of ten months' duration, 
complete recovery. 

C. M.. ^et. IT. Diathesis nervous. Disposition excitable and sensi- 
tive. Comes of a nervous stock ; and a maternal cousin is insane. He 
had been in low spirits, and rather more sensitive and shrinking than 
usual. There was no proof of masturbation, though I supposed that his 
thouo-hts had been erotic from various small indications. Beino- very 
strictly brought up, all the outward influences had been in favor of severe 
repression of the nisus generativus. The exciting cause was said to 
have been a fright, but I scarcely think there was sufficient proof of this. 
One day he suddenly began to roar and shout, and say he was first 
Christ, and then the devil, and to be most violent to those about him. 
He orot so ill and so unmanao-eable that he had to be removed to the 
asylum the same night his attack began, which in most cases would be 
considered a premature measure, considering the public feeling existing 
about hospitals for the insane, and the harm a residence in one may do 



STATES OF MENTAL EXALTATION. 151 

to a man's prospects, however inucli it may be true that the best treat- 
ment for the patient could be got there. His delusions were transient, 
most of them being of a religious nature. His condition was that of a 
typically acute delirious mania when let alone ; but when his attention 
was roused by questioning, he could answer some simple questions co- 
herently, though not correctly, his memory being much impaired. He 
was slightly built, not so fat as he should have been ;'his pulse very weak, 
116; and his temperature 99.6°, and 100° in the evening. He had a 
warm bath at 98°, with cold cloths to his head for fifteen minutes, and a 
draught of ten grains of chloral, and forty-five grains of bromide of po- 
tassium, with two drachms of tincture of valerian. He scarcely slept at 
all, and next day his condition was still most excited and violent, but he 
was kept walking about by two attendants for five hours, though very 
intractable, throwing himself about, etc. Next night he got a bath for 
twenty minutes, and the same draught, and slept six hours. Next day 
his temperature was normal. . He was less excited, and w^alked better. 
The same treatment was continued, and in three days he w^as still better, 
and in eight days he w^as playing cricket. He had a relapse on the tenth 
day, though he did not get nearly so excited as at first. He had two or 
three milder relapses within the next tw^o months, but at the end of that 
time he was practically well, and in three months he was discharged re- 
covered. His treatment consisted of an almost indefinite allowance of 
milk and eggs, almost no animal food, fresh air, exercise to fatigue all 
day, baths, warm at first, and mild shower-baths as he recovered, and 
cod-liver oil emulsion, with the hypophosphite of lime. He gained al- 
most a stone in weight, but did not grow any more manly in his form, 
nor did his beard grow. 

He kept well enough not to be sent to the asylum for three and a half 
years, but during that time he constantly had threatenings of his com- 
plaint, and was at times unable to follow any continuous occupation. 
After that time he had another attack of a much more mild kind of acute 
mania. He was delirious, not violent, early ceasing to take any interest in 
anything ; seeming to live in a morbid subjective mental atmosphere of 
disordered imagination ; talking to himself incessantly, not sleeping well, 
was constantly grimacing, gesticulating, and fighting imaginary persons 
in the room round the wall. When he was spoken to, he Avould pick 
himself up and answer pretty rationally. This is a condition that 
puzzles many persons. It looks like dementia, while in realit}^ it is a 
subacute form of mania, which makes all the difference in the prognosis, 
and sometimes in the treatment. He was tried at home, in charge of an 
attendant to control him, to get him to walk out, etc., but he rather 
rebelled. Patients are of course never so easily controlled at home 
as away from it ; especially it is hard for the master or mistress of a 
household to be controlled in their own house, where before every one was 
under them. In an institution, on the contrary, among strangers, under 
certain definite rules of living, and where there is obviously the means of 
enforcing medical orders, a patient must be very insane not to conform to 
tlie orders given as to his treatment, and to the general way of living of 
the place. This is very often seen when patients come to asylums. At 



152 STATES OF MEXTAL EXALTATION. 

home tliev had been very difficult to manage, or most obstinate, -ff-hile 
from the moment they come into the institution they give no trouble at all. 

He had again to be sent to the asylum, and he was found to have lost 
in T^eight, and to be ill-nourished and wanting in nervous tone and 
nutritive energy. His muscles were flabby and his skin pale, and his 
appetite for food not keen. He was put on quinine and iron, cod-liver 
oil, milk, and eggs in large quantities, his skin well rubbed night and 
morning with a dry towel : he got mild shower-baths, and took much and 
increasingly vigorous exercise. He gradually gained in weight, in 
nervous tone, in self-control, in power of applying himself to work, 
in his interest and power of attention : he got more manly in form, and 
filled out into a strong, vigorous-looking young man. It took him ten 
months to recover. This was a case in which I was very much afraid of 
dementia. I think this Avould have certainly resulted had not right 
treatment been vigorously adopted. In such a case the brain is in much 
the same state as in certain forms of dementia, lyJus a little maniacal 
excitement — but that makes all the difference. 

I had once under my care — C. X. — a young lady of twenty-three, of a 
nervous diathesis, and with a strong heredity to insanity, who. bathing 
while menstruating, became slightly depressed, then had an attack of 
slight exaltation eveiy month, followed by a day or two of modified 
stupor, at the time she should have menstruated, but did not. After a 
few months menstruation returned, but came on every fortnight, thus 
reducing her strength, and causing anaemia. At the usual time of men- 
struation on one occasion a most violent attack of acute mania came on, 
with incoherent delirium and such excessive violence, that she neaTly 
killed a relation. Two trained female attendants could not control her at 
home. Her temperature was 103°, one of the highest I ever saw from 
uncomplicated brain exaltation, and she had to be taken to the asylum 
within twenty-four hours after the commencement of the attack. For 
the fii'st fortnight she remained in the most acute state of excitement 
I think I ever saw. It took five attendants to restrain her. dress, undress, 
and have her walked out. which we did eveiy day. When she would 
not walk she was allowed to roll on the ground. She soon became less 
excited, but at the next menstrual time she had a relapse, and was as bad 
as on admission. Though apparently absolutely delirious, and without 
power of attention when excited, yet, when the attack passed off, 
she could describe what had occurred very accurately for the most part, 
though distorted in some respects. She had no realization that she had 
been so ill, and. therefore, thought she was unnecessarily detained in the 
asylum, and that the attendants" restraint of her violence had been simple 
cruelty on their part. There is a psychological fact Avith which we are 
very familiar in asylums, which was most marked in her case, though it 
occurs more or less in most cases of mania and melancholia. As the 
patients first become coherent and sensible, they are much more unrea- 
sonable about going home at once, and about getting all they fancy, and 
about being controlled, and about all sorts of things, th^n when they get 
quite well. They usually attribute any nervous symptoms they have to 
their being ''kept in the asylum." and aver with daily iteration that, if 
kept much longer "in a madhouse" or ''among maniacs,'" they will 



I 



STATES OF MENTAL EXALTATION. 153 

certainly become insane. Their friends do not understand that this is the 
ordinary half-way house to complete recovery, and sometimes remove them 
home, often with very bad results. When they have quite recovered, such 
patients are commonly patient and reasonable about going home, and 
often recognize how necessary restraint has been. Some patients never 
do this, however. C. N. had relapses of a less severe character, about 
the menstrual periods, getting more and more reasonable during the 
intervals. In six months she was so Avell that she was taken home, not 
exactly against my advice, but not quite with my concurrence, as she had 
not menstruated, and was excitable. 

The question of when recovery has taken place is often a difficult one 
to decide in mental diseases. You have to take the temperament, dispo- 
sition, and normal state of mind into account. The same standard cannot 
be applied to persons of different education, temperament, or nationality. 

The relation of menstruation to mental disease is a very important one, 
of which I shall treat more fully under uterine insanity ; but I may say 
now generally that in most cases of acute mania cessation is the conse- 
quence, and one symptom of the morbid brain excitation, and not its 
cause, and the restoration of the function is the result of improved brain 
and bodily health and condition. I never adopt special means for its 
restoration until the patients are strong and have become fat, but at the 
same time I regard mental recovery in a woman as being likely to be 
much more stable and less liable to relapse after the menstrual function 
has become normal. I always like to see it normal before I recommend 
the patient's removal from the asylum. 

The treatment in this case was the same exactly as the last. Unfortu- 
nately, she was threatened with a relapse after going home, but it was 
summer, and I sent her to vegetate and live in the fresh air at the 
seaside, where her recovery was completed. She then went to work, and 
worked too hard, and has since had two attacks of the same kind, but of 
shorter duration and slighter character, in the four years that have 
elapsed since her first recovery. 

Both of these cases (C. M. and C. N.), though cases of acute mania 
in the classification founded on mental symptoms, are cases of the insanity 
of adolescence, when looked at from the clinical point of view. 

Though recovery from acute mania is usually a gradual process, yet at 
times it is sudden. Why this should be in certain patients I am quite 
unable to tell, nor have we any means of predicting beforehand in any 
case that it will terminate in recovery in that sudden way. This is an 
example, which was cured suddenly by a local inflammation : 

C. 0., set. 44, a married woman, with several children. No heredi- 
tary predisposition, the sole cause being over-work in her household and 
over-anxiety about her family. She was of an ''anxious disposition'' 
and a nervous diathesis. She became irritable, quarrelsome, restless, 
sleepless, excited, and totally changed from her natural Avays about a 
week before her admission, and this condition quickly passed into one 
of acute maniacal exaltation, noisiness, singing, fleeting delusions, vio- 
lence, and excitement, witli no memory, no self-control, and no aftection 
for her children, of Avliom she had been passionately fond. Some- 
times she would be perfectly taciturn and obstinate for an hour or two, 



154 STATES OF MENTAL EXALTATION. 

would not open her eyes, answer questions, eat, or walk about. She had 
not slept for several nights before admission, and had refused food. 
When brought to the asylum she was actually excited, noisy, shouting, 
sino^ino;, sesticulatino-, struo:orlino^, resistino^, violent, makino- faces and 
facial contortions, putting her tongue out, but would not answer questions 
or attend to anything said to her. The common sensibility seemed quite 
blunted, so that she felt no pain. Her skin was dry, tongue furred and 
dry, appetite gone. Pulse 126, small and weak. Temperature 101.2°. 
For the first four days she remained in this state, taking scarcely enough 
food, and that with extreme diiBculty, and spending her time partly out 
of doors, under the care of two attendants, and partly in the padded 
room when in the house. On the fifth dav, ha vino; refused food altoo-ether, 
she was fed with the stomach-pump. This Avas done with extreme diffi- 
culty, on account of her holding her teeth together most closely. The 
steel mouth-opener, though padded with tape, she crushed through a 
tooth by the force with which she bit it. This caused a good deal of 
inflammation in the gums and jaw, spreading back to the parotid gland, 
which became enormously swollen and suppurated. But as the inflam- 
mation spread the maniacal condition subsided, so that on the tenth day, 
when the temperature was 106°, and the patient very weak and exhausted 
indeed, the restlessness and excitement had quite ceased, and she took 
both food and stimulants. She was confused in mind, but not otherwise 
maniacal ; and, though she nearly died from the combined general 
exhaustion and local inflammation, she never became maniacal again, 
steadily progressed towards recovery, mental and bodily, and was well 
in a month. 

This is one example of very many cases I have met with, where a 
local inflammation, a fever, an internal disease, a carbuncle, a crop of 
boils, or septic blood-poisoning, have cured insanity. We try to do the 
same thing sometimes in cases that are strong in body by severe blister- 
ing, but seldom succeed in producing the same marked and immediate 
efi'ect. I believe that some day we shall hit on a mode of producing a 
local inflammation or manageable septic blood-poisoning, by which we 
shall cut short and cure attacks of acute mania. I have been most im- 
pressed by some of the cases I have met with. But such intercurrent 
diseases do not always cure. I have often seen them occur in cases of 
acute mania, and do no good. I suppose, in fact, the failures may be 
more numerous than the successes, but the latter naturally make more 
impression on one's mind and loom larger in one's field of experience. 
The following was a most striking case of cure, sudden and unexpected, 
after hope had been nearly given up : 

C. P., aet. 26. A married woman who had sufi'ered from acute mania 
connected with lactation for nine months. The symptoms had come to 
have some of the mental enfeeblement of dementia about them ; but still 
there was the maniacal excitement, the presence of which prevented in 
my mind an absolutely unfavorable prognosis. She had been discharged 
from another asylum as virtually incurable. She had several cuts on her 
hand on admission, caused by her having broken a window. Fortunately 
for her, one of them got some dirt into it, and the hand inflamed badly, 
with a nasty septic-looking inflammation that ran up the lymphatics, and 



STATES OF MENTAL EXALTATION. 155 

was attended by intense pain, and great general disturbance and prostra- 
tion. It suppurated, and discharged a dirty, sanious pus. But the effect 
on the brain condition was magical. This nine months' maniacal, 
destructive, dirty, violent woman, caring nothing for her husband or 
children, or the common decencies of life, became quite gentle and man- 
ageable as the inflammatory fever and the local inflammation progressed. 
At first confused in mind, then awaking to all the farmer associations of 
her life, she inquired for her children, and became in a fortnight a sane, 
pleasant, lady-like woman, with all the charms and graces of womanhood. 
Such cases puzzle one exceedingly. That period of nine months, during 
which the neurine of the brain convolutions had been energizing morbidly, 
so that every mind function — intellectual, affective, instinctive, and 
mnemonic — was utterly disordered, clearly left no trace of structural 
change. Unfortunately I have to give the sequel, which is not so 
pleasant. She kept quite well for three years, and unluckily had a 
child, and while nursing it (neither of which she ever ought to have 
done), another child died, causing her great grief. She again became 
maniacal. I blistered her head repeatedly and severely, and rubbed 
in irritants with marked benefit, but not with such absolute and striking 
effect as on the first occasion, because probably I could not set up a real 
inflammatory fever. I put her on bromide of potassium and cannabis 
indica, with very marked benefit. ' She got better in four months, and 
went home quite well in all respects. In a year she became maniacal 
again, and this time no treatment has been of any avail. She remains 
ill for over two years, and, I fear, is now incurable. 

The good effect of the treatment by hot baths was well seen in the fol- 
lowing case of C. P. A., a young man who, as the result of over-work, 
too little fresh air and relaxation, became morbidly exalted in mind, 
restless, sleepless, talkative, and changed in general mental demeanor. 
While in this state he was more active mentally than he had ever been in 
his life. He wrote an article for the most brilliant weekly journal of the 
time, which was accepted and inserted — the only article he ever wrote in 
his life. His condition soon passed into violent excitement, constant 
extravagant talking, and fleeting delusions of ambition and extravagance. 
His conduct became violent, destructive, and unmanageable, and he was 
in that condition when I saw him. I got a first-rate, strong, trained 
attendant, and we give him two baths of about 104°, with cold to his 
head. The immediate effect of this was lowering, and he nearly iainted 
before he was taken out of the second, but his excitement and talkative- 
ness and his delusions were calmed and diminished. He got drachm 
doses of the bromide of potassium repeated three times during the night, 
and for the first time for about ten days he had a, good sleep. By the way, 
I should have mentioned that between the baths he Avas taken out into tlie 
open air and walked about for several hours till lie was pretty nearly 
exhausted. Next mornino- all the most violent and unmanaojeable of the 
symptoms were found to have passed off, and under the treatment of baths 
and bromide, with plenty of exercise and unlimited milk and liquid 
nourishment, he made a speedy and perfect recovery in about a week or 
ten days Avithout relapse and without complication. In a fortnight 



156 STATES OF MENTAL EXALTATION. 

he was able to go aAvay for a change, and has since been as vigorous a 
man, mentally and bodily, as he ever was, conducting a large business. 

Acute mania sometimes exhausts the strength of the patient, and kills 
in spite of treatment, as in the following case of C. Q., set. 34, suffering 
from the third attack of mental disease, the two former havino; been 
attacks of melancholia. She had a sister insane, and a brother an 
imbecile. She had been ill for about a month, being much excited, and 
refusing food. On admission she was acutely maniacal and delirious, 
with no memory, and no power of attention. He pulse was 98, her 
temperature 99.6°. and her general condition weak. She refused food, 
and though fed regularly with the stomach-pump, the excitement con- 
tinued, and she got more and more exhausted, though after the first 
feeding with custard, wine, and quinine, she Avas less excited, and slept 
for the first time for a week, but this good result did not continue, and 
she died on the fifteenth day. A post-mortem examination showed the 
traces of old morbid action in the shape of thickened and adherent dura 
mater ; the vessels of the brain being engorged ; but its substance, so far 
as our means of investigation enabled me to examine it, was normal. 
There is, of course, no reason why a mere dynamical brain disturbance 
should not kill and leave no structural trace, any more than that it should 
for months abolish judgment, affection, and memory, and then pass off 
and leave the brain and all its functions intact. The most common j90S^- 
mortem appearances in the brain in those cases that die of acute mania 
are intense hyperaemic conditions, as represented in Plate III. The con- 
stant occurrence of such hypersemia in limited areas shows that the vaso- 
motor disturbance is not uniform all over the brain. In the case from 
which Plate III. was drawn, the congestion occurred along the whole 
inner margin of the gray substance of the convolutions as well as in areas. 
I have always looked on this irregularity of blood-supply to the brain, 
resulting from such vaso-motor spasm at some parts, and paralysis at 
others, as being most important in throwing light on the general pathology 
of acute insanity, but I do not regard any vascular disturbance as a 
primary cause of the disease. 

The following case of acute mania was caused evidently by a pathological 
deposit of a kind yet undescribed all through the convolutions. C. Q. A., 
set. 50, had been insane for only a few days, and was acutely excited and 
maniacal on admission. Her temperature was 98°, and her pulse 88. 
She was deliriously maniacal, unconscious, restless, sleepless, and noisy. 
In a fortnight she became more rational and quiet, and could do some 
work. Then in another week the acute deliriously maniacal condition 
returned. She got more stupid and irrational, and died four weeks after 
admission, and five weeks after the commencement of her insanity. 
With the late Dr. Joseph J. Brown, then the assistant physician in charge 
of the department, I made the post-mortem examination ; and the naked- 
eye appearances were, like the microscopic appearances afterwards 
discovered by Dr. Brown, quite unique and hitherto undescribed. The 
pia mater was milky and thickened, and stripped readily off the convolu- 
tions. Convolutions were somewhat atrophied. In the convolutions 
around the island of Reil there were seen a number of small pellet-like 
bodies the size of pin-heads, and of a glistening appearance, scattered. 



PLATE III. 





, Watinaou .<;> Jons Litbo , Edbbttrgji 



STATES OF MENTAL EXALTATION. 157 

When closely examined it was seen that these sago-like bodies were more 
or less distributed over the gray substance of nearly the whole of the con- 
volutions of the cerebrum. The outer layer of the gray matter of the 
convolutions was quite distinct from and stripped like a sheet of wet paper 
off the under layer. Dr. Brown prepared many beautiful sections of the 
convolutions so affected, and was to have fully described the lesion, which 
was new and most interesting. A deposit of a new material had taken 
place, as represented in Fig. 5, Plate VIII., all through the gray 
substance of the convolutions, but chiefly in its inner layers, and extend- 
ing in some parts into the white substance. It was in some places in 
single spots, with a nucleus in the centre of each, but no other trace 
of organization visible ; in other places in immense lobulated masses, or 
in great oval bodies with a nucleus in the centre of each, quite visible to 
the naked eye. It was deposited in masses round the arteries in many 
places. It seemed as if at the least two-thirds of all the gray substance 
of the convolutions were replaced by this deposit. It took on the carmine 
stain strongly, and looked more like a waxy material than anything else, 
but its exact composition I do not know. It was evident that it was a 
chemico-vital product deposited round nuclei. 

Many questions suggest themselves in considering such a case. What 
a comfort it would be were the pathology of every case of acute mania as 
definite as this seemed to be ! The discouraging thing is, that no such 
deposit is needed at all to produce mental symptoms like those of C. Q. A. 
How long was this deposit in forming ? Surely longer than the five 
weeks she was insane. And she became wonderfully rational and 
coherent after the first three weeks with her brain convolutions diseased 
in this way, just as a general paralytic often gets almost rational for 
a time with his convolutions diseased. It is clearly not only a deposit of 
this kind, or a pathological change in the cells, but the morbid energizing 
that such lesions give rise to, that really produce the symptoms of acute 
mania. 

Delusional Mania. — This is a condition analogous to what I have 
described as delusional melancholia, the general symptoms being maniacal 
instead of melancholic, and centring round a fixed delusion or set of 
delusions. I have now under my care a woman — C. Q. B. — who shouts, 
scolds, and is violent almost all day, alleging, as the reason of her con- 
duct, that her children are below the boards of the floor, and that she 
hears them being tortured by villains, who are to kill them. I have a 
man who shouts and preaches, and warns the sinners of the world in a 
most riotous and noisy way of the doom that awaits them, saying that 
the Lord had commissioned him to do so. Delusional mania is in fact 
delusional insanity, plus maniacal conduct. Such cases sometimes 
recover, but when the fixed delusioiuil condition has lasted long the prog- 
nosis is bad. 

Chronic Mania. — This is simply acute mania running on into a 
chronic course. The division line that marks ofl" acute from chronic 
mania must always be an imaginary, arbitrary, and unscientific one. 
The term of twelve months tliat I have adopted has this disadvantage, 
that after that time many cases are curable, while we usually think of 
chronic mania as being virtually an incurable disease, endiui:; in death or 



158 STATES OF MENTAL EXALTATION. 

dementia. The long continuance of a maniacal condition of the brain 
always causes an alteration of the symptoms, as compared with those of 
recent acute mania. We seldom or never have any tendency to delirious 
mania, with dry tongue, high temperature, and risk to life, from the 
intensity of the disease. To be able to live long, suffering from chronic 
mania, implies a strong constitution, with good digestive and assimilative 
power. Though the absolute sleeplessness of acute mania is not present, 
yet many cases of chronic mania sleep exceedingly little. It may seem 
incredible, but we had once at Morningside, a woman suffering from 
chronic mania, w^ho for eighteen months was never found asleep by the 
night attendant, who visited her every two hours every night. She 
must have slept, of course, but her sleep was so light and so short that 
she was always awake every two hours. Not only did she not sleep, but 
she was restless, noisy, singing, tearing her bedding, and, when she had 
nothing else to do, gnawed with her teeth and scratched with her nails 
the wood-work of her room into great holes. But some cases of chronic 
mania sleep quite w^ell, and almost the natural time, and yet during the 
day they continue excited, restless, and destructive. 

There is usually a spice of the enfeeblement of mind of dementia in 
chronic mania, notably the memory is impaired, a rational interest in 
anything cannot be roused, and the habits, instincts, and fine feelings are 
degraded or dulled. The affective power is usually almost paralyzed. 
There is no proper care for children or tender affection for anybody. 

As regards treatment, an asylum is the only proper place for such 
patients. I have seen them kept at home, or boarded in private houses, 
but I have seldom seen a patient very happy there, or the arrangement 
very satisfactory. I shall never forget a visit I once paid to a case suf- 
fering from chronic mania — C. R. — with short aggravations each day of 
w^ild delirious fury. To provide against these, two large rooms in a 
handsome villa had been divested of furniture, the windows boarded up, 
and the w^alls left to the unrestrained destructiveness of the patient. I 
stayed with her in this apartment during a paroxysm of her disease, and, 
in twenty-two years of life as an asylum physician, I have never seen 
anything so completely parallel to the famous maniac scene in Charlotte 
Bronte's Jane Eyre. The patient tore her clothes to ribbons, shouted 
and howled, and made a barking noise like a dog, bit her skin, dashed 
herself against the w^alls, and dug into the plaster and wood- work w^ith 
her nails till they bled, and she smeared the blood over her face and body. 
After many years of this life, her relatives at last got over their preju- 
dices against an asylum, and sent the patient to Morningside, where, after 
a few^ months of hard walking in the open air, occupation, dancing, and 
a regulated life, she is an ornamental and amusing member of our com- 
munity, very happy, and always averse to the idea of leaving the asylum. 
She takes her paroxysms still, but they are shorter and much less severe, 
and her attendant stays with her, which soothes her. One of the great 
improvements that has taken place in modern asylum management has 
been that rational physiological outlets are provided for the morbid mus- 
cular energy of the cases of chronic mania. They are neither confined 
in their rooms nor within " airing courts " enclosed by high walls. They 
are made to walk about. They are made to wheel barrows and dig on 



STATES OF MENTAL EXALTATION. 159 

farms. They are encouraged to dance, and they are well fed. Most of 
them eat enormously, and if they have not enough to eat they fall off, get 
worse in their mental state and in their habits. Many of them can be 
got to expend their energies in hard regulated work, and are the very 
best workers on the farms and in the laundries of asylums. They are 
not all, of course, furiously maniacal. Some of them simply have a 
slight morbid excess and exaltation of function of the Brain convolutions, 
shown by restlessness, want of affection, and want of self-control, but are 
not incoherent. If they are kept at work, the most objectionable and 
repulsive parts of the older asylum life is avoided in great measure, and 
the " refractory wards," with their noise and danger, are not needed. 
The scenes with patients, attendants holding them down and removing 
them into the seclusion of their own rooms, are few. No doubt there are 
risks run in the present system to patients and their guardians, but I 
believe the risks are much less in reality than under the old system, for 
the patients are not so irritable, not so revengeful, and not so dangerous 
generally. 

The folloAving was a case of mania, acute at first, with temporary 
recovery, then a relapse, and chronic mania for three years, then death ; 
all the mental symptoms being those of the ambitious delirium of general 
paralysis. 

C. Y., aet. 67. A man of sanguine temperament, very frank and 
enthusiastic disposition, and industrious habits. For many years he had 
devoted himself with zeal, enthusiasm, and industry, as to a real business 
in life, to the study of a particular department of knowledge, until he 
was one of the acknowledged authorities on the matter. He was a man 
of much individuality of character, amounting almost to eccentricity, and 
he evidently had a high opinion of himself and of what he had done. 
His habits were so industrious in following his special work that he gave 
himself too little sleep, and this, I think, was the exciting cause of the 
attack I am about to describe ; the predisposing cause being a heredity to 
the neuroses, which some of his friends were so anxious to deny, that I 
concluded it must exist ; in fact, I had evidence, by seeing some of them, 
of its existence. His disease consisted of a gradual evolution and exag- 
geration of certain points in his character into excessive and morbid 
prominence. His good opinion of himself and the value of his work, 
which before had merely been apparent in small things, now became 
evident beyond what sensible men ordinarily display. He became rest- 
less ; his sleep power seemed to have gone, so that he sat up all night, 
and he became irritable without reason. He went about among his 
friends, and talked all the time, his natural enthusiasm about his special 
work taking ridiculous forms. He developed openly an idea that he 
seems to have had vaguely held, but did not speak about it, that he was 
the heir of a great Scotch historical house. In a certain nascent degree, 
the idea that they are the heirs, or at all events the members, of great 
historical families, is a most common psychological peculiarity of vast 
numbers of perfectly sane Scotchmen ; and when they have attacks of 
morbid mental exaltation this vague fancy, and perhaps longing, whicli 
before had no more practical effect on their lives than heiglitoning their 
self-respect, becomes a foolishly expressed delusion. If I have had one 



160 STATES OF MENTAL EXALTATION". 

Lindsay as a patient who was the rightful heir to the earldom of Balcar- 
res, I have had certainly a dozen. In about a fortnight C. Y. was 
absolutely incoherent, swearing, and fancying he w^as in heaven, this 
condition being attended with great violence to those about him, and 
destruction of objects that he had valued most highly. In another day 
or two he became quite delirious, and he would take no food, and had to 
be sent to the asylum. On admission he was maniacal and furious, 
attacking those near him very violently, and at times dashing himself on 
the floor in a way that might have hurt him. He was almost incoherent, 
but his ideas were all most exalted. He had millions of money, could 
make us all dukes, etc. He would make a man a duke one moment, and 
strike him suddenly the next. His case was certainly very exceptional 
in its tendency to impulsive violence. He was in this respect more like 
the dangerous maniac of the popular imagination than most of our 
ordinary patients. With this intense excitement, and with much mus- 
cular strength, his pulse was feeble, his tongue dry, his face haggard, and 
his whole bodily condition one of great weakness and danger to his life. 
By dint of feeding, stimulants, and taking him into the open air under 
the charge of tried attendants, he gradually improved. His mental state 
was all the time exactly that intense exaltation, that morbid mental 
"expansion," that "ambitious delirium," or "mania of grandeur," which 
we find so commonly in general paralysis, and which some physicians 
suppose to be characteristic of that disease. Everything about the place 
was of the finest, his treatment was very skilful, the physicians were 
most eminent, and the attendants were most kind. In the bemnnino; of 

' CD O 

his disease I often was on the look-out for the motor symptoms of general 
paralysis, without which it is, of course, utterly unjustifiable to diagnose 
that disease. In three months he had become quiet in manner, self-con- 
trolled, and rational, but had just a suggestion of his former state of 
mind in being too pleased Avith things, and too grateful for little kind- 
nesses. His friends thought him quite well, and he was removed home 
with my approval. But he had not been home a day when he set to 
work .to his old employment and studies with a sort of unreasonable 
enthusiasm. Sitting up nearly all night, he soon got unsettled, his 
exaltation of mind came back ; he became dirty in his habits, impulsive, 
and utterly impatient of contradiction. If his orders were not at once 
carried out, he would get into a sort of maniacal rage. In seventeen 
days he had to be removed back to the asylum, and though not so deli- 
rious or so w^eak as on his first admission, he was very excited. He would 
come up and be most pleased to see you, and in a moment, sometimes 
with some little provocation, such as your not agreeing at once with him 
that he was an Earl, or sometimes without, he Avould strike you suddenly, 
very often going doAvn on his knees immediately after, and in a theatrical 
manner begging your pardon, and hoping he had not oifended you. In 
meeting you he would come up with a profound bow, place his hand 

on his breast, and hope "Sir is well." His insane grandeur of 

manner was often very grotesque. He would talk for a minute in this 
high-flown way, and ask, perhaps, for a book or a newspaper. Wiien he 
got it, he would turn round, and in a surreptitious way would tear it up. 
He was given to impish tricks and mischief of all kinds. His habits 



STATES OF MENTAL EXALTATION. 161 

were dirty in the extreme ; he tore his clothes and his bedding, and he 
never could he left for a moment without his getting into some mischief. 
He reminded me of the clown in a pantomime, only combining with his 
mischief a far more magnificent manner than any clown could assume. 
This went on in spite of all treatment, medical, moral, or dietetic, for 
three years, at the end of which time he died of internal cancer. The 
chronic mania, no doubt, weakened his brain functions, and he presented 
some few of the symptoms of brain enfeeblement towards the end. His 
memory was worse, he was not so coherent, he was more silly and childish 
in his ways, and the maniacal symptoms were not quite so intense. 

On post-mortem examination we found some thickening of the mem- 
branes, some convolutional atrophy, some disease of the coats of the ves- 
sels, some local congestions, and some few spots of ramollissement, but 
nothing pathognomonic, nothing so characteristic that by seeing it one 
could say that the man labored under chronic maniacal exaltation. This, 
of course, merely shows the insufficiency of our present means of brain 
examination, for assuredly there must have been organic changes after 
so long a disturbance during life. That any pathological changes will 
ever show the special mental peculiarities of such a person, his ambitious 
mania, his loft}^ o^ inion of himself, his destructive tendencies, is more 
than we can expect, for such things were the evolutions of his tempera- 
ment and the skeleton of his normal mental framework, which the self- 
control that we call sanity and the customs of civilized life induce men 
to hide and keep under, just as they do their day dreams and their pet 
ambitions. The onset of the cancer, with its cachectic and exhaustive 
tendency, may have been the exciting cause of the maniacal attack, and 
also the reason why recovery did not take place. 

The chances of recovery from mania after twelve months' duration 
diminish very much as time goes on, more so than in the case of melan- 
cholia ; but we do not pronounce a case incurable for a long time, so 
long, in fact, as the morbid brain exaltation lasts, and dementia does not 
supervene. In the prognosis of mania, where there is exaltation there 
is hope. I had a patient — 0. Y. A. — discharged recovered two years 
ago who had been for eight years suffering from chronic mania of an ex- 
tremely bad type, with, as I thought, many of the signs of dementia. 
I had shown her to my clinical class on several occasions as a typical 
case of chronic mania. The chances of recovery are in inverse ratio to 
the length of the disease after the first two years. After five years re- 
covery is the rare exception ; but I have known it take place after even 
twenty years. 

Ephemeral Mania (Mania Transitoria). — This term is used to 
describe a somewhat rare form of maniacal exaltation Avhich comes on 
suddenly, is usually sharp in its character, and accompanied by incoher- 
ence, partial or complete unconsciousness of familiar surroundings, and 
sleeplessness. An attack may last from an hour up to a few days. I 
was once called in to see a young man in Carlisle, C. Z., a patient of the 
late Mr. llo1^'>rt Brown, who suddenly, witliout premonitory sym})toms 
and without any apparent cause, had in the afternoon, in the midst of 
his Avork, become incoherent in his speech, talking continuously, restless, 
pushing about the furniture, did not know his relations, and expressed 

11 



162 STATES OF MEKTAL EXALTATION. 

many fleeting, unconnected delusions. He was not very violent or diffi- 
cult to manage. He would take no food or medicine, and there was no 
means of making him do so, and no warm bath to be got, so he was left 
alone under the charge of an attendant. He did not sleep that night, 
but towards morning he became less talkative and restless, he began to 
know those about him, then there was an hour or two of stupidity, con- 
fusion, and lethargy, and next day by mid-day he was himself again, 
went to his work, and had no relapse. That was the first case of the 
kind I had ever seen, and it was very instructive to me, for I always 
since ask myself, when called into any suddenly occurring case of mania. 
Is it a case of mania transitoria ? Since then I have met with many 
somewhat similar cases, both among patients who were convalescent in 
the asylum, especially among epileptics, and also in the patients who 
were not in the asylum. I think cases of mania transitoria result from 
the following causes. Most of them are epileptiform, are, in fact, of the 
nature of the mental epilepsy of Hughlings Jackson in cases where dis- 
tinct motor epilepsy does not exist. I believe the case of C. Z. w^as of 
this character. Others are examples of the epileijsie larvee of Morel, 
masked epilepsy, where a mental explosion takes place, instead of an 
ordinary epileptic fit. A few of the cases result in young persons from 
slight moral or physical causes upsetting brains of intense instability 
that have strong neurotic heredity. There are some such brains so easily 
upset that a gust of passion, a sudden stoppage of menstruation, a slight 
excess of alcohol, of sexual intercourse, or of masturbation will make 
them delirious, and this may only last for a short time. All the symp- 
toms of mania transitoria may be seen in the incubation of and during 
febrile and inflammatory complaints, such as scarlet fever, typhus and 
typhoid, local inflammations, etc., in unstable brains that are upset by 
very little, through a process of what the older authors called metastasis. 
I have seen ephemeral mania after erysipelas. 

The great question in regard to ephemeral mania is this — Can we tell 
it by any special symptoms ? There are no definite symptoms that I 
know by which we can tell that any maniacal attack is going to be 
ephemeral. There is always a presumption that when an attack begins 
very suddenly, it may end suddenly, and if such an attack occurs in a 
young subject with strong heredity to insanity, whose diathesis has been 
very neurotic, and whose brain has manifested unstable tendencies, it is 
right to keep this form of mania in mind, and not be in too great a hurry 
in sending such a case to an asylum. The treatment is the same as that 
I have recommended for acute mania, only the bromides and cold appli- 
cations to the head are especially indicated. I imagine that family doc- 
tors who attend many nervous families could tell of attacks of what are 
really ephemeral mania, but are naturally called by all sorts of euphem- 
isms, "nervous attacks," "hysterical attacks." I once saw an attack of 
ephemeral mania come on and last a few hours, in a girl who had usually 
exhibited her neurosis by attacks of hysteria. 

Homicidal Mania. — In popular and sometimes in medical phrase- 
ology, "homicidal mania" means any kind of mental disease where there 
is any attempt or desire on the part of a patient to kill. But, as you 
have seen, the homicidal desire may occur in melancholia, and is often 



STATES OF MENTAL EXALTATION. 163 

associated with the suicidal feeling. As we shall see, it may occur as an 
uncomplicated impulse, not accompanied by depression or exaltation of 
mind, and it then stands as one of the varieties of impulsive insanity. 
But at present we are to view it as one of the chief symptoms of certain 
forms of maniacal exaltation. In this it occurs in four forms: First, 
and most commonly, from delusion ; e. g.^ that persons attacked are per- 
secuting the patient, or are going to kill him. Second, from sheer ex- 
cess of motor energy, which vents itself, as it were, in killing, as it does 
more ordinarily in smashing, fighting, or tearing. Third, from a distinct 
morbid desire, impulse, and craving to kill. Fourth, homicidal attacks 
are made in the unconscious delirium of acute delirious mania without 
"motive," without "intent." Of the first kind was the case of C. N. 
(p. 149), when she attacked the attendant on admission, under the delu- 
sion that she was her enemy and going to injure her. 

We had in Morningside Asylum, when I was an assistant physician 
there in 1860, a remarkable case of homicidal mania, a most graphic 
account of which was published by my friend and then colleague, Dr. 
Yellowlees.^ The man's name was Willie Smith, who, beginning with 
an attack of what was evidently simple mania in 1829, and taking to 
publishing his own effusions, wrote thus : 

" There's Willie Smith the carpenter, 
Become at last a publisher ; 
You'll find his works in rhyme and prose 
Throughout this land o' cakes and hrose ; " 

and because his contemporaries laughed at him, and the boys called him 
"Whisker Willie," broke his glass, and blew "smoke out of a horn full 
of lighted tow into my shop," he applied to the law. And, by the way, 
what a psychological study is the boy's instinct in finding out weak points 
of inhibition, his altogether uncontrollable impulse to probe them when 
found, and his delight at the result ! And the magistrates would give 
Willie no redress. Because of these things, he imagined he Avas perse- 
cuted, and planned to execute revenge all the rest of the thirty -two years 
of his life. He was a perfect example of the French megalomania — ele- 
vated ideas about himself and his powers, combined with ideas of perse- 
cution — and, in addition, with strong and persistent homicidal tendencies. 
With loaded guns, daggers, spears, axes, swords, extemporized weapons 
of all sorts, he meditated and tried revenge and homicide. In the s^ol, 
the poorhouse, the asylum, he made repeated, persistent, and numerous 
attempts to murder attendants and physicians, and was the terror of all 
who knew him. "It is scarcely possible to find language strono- enoui^h 
to describe the bloodthirsty passion which possessed the man, the devilish 
intensity, deliberation, and determination with which all his attacks were 
made, or the fiendish delight with which he gloried in relatini^ them." 
Yet all the time he had " exaltation of the feeling of pride, and hio;h 
ideas, and delusions regarding his own powers and capabilities, particu- 
larly as an engineer, architect, and musician." A visit to liim was the 
sight .of the asylum, and a thing to be remembered for manv vears. I 

1 Edin. IMcd. Journ., Augiist, 02. 



164 STATES OF MEXTAL EXALTATION. 

do not know how it is, but such picturesque cases of insane would-be 
murderers do not seem to occur now. The fewer precautions are taken, 
the less need there seems to be for them. "When he died his head was 
found to have undergone great changes in shape, as compared with a cast 
taken twenty years before, and his brain was much atrophied. 

I had a patient once, C. Z. A., set. about 28, with a strong heredity 
towards mental disease, who had been working too hard at brain work 
that was uncongenial to him. and also had had a disappointment, and who 
had previously shown only a little mental confusion for a week, when 
suddenly, without warning, he made a homicidal attack on his brother 
when taking a walk, under the delusion that his brother wanted to do him 
harm. This was really the fii*st distinct symptom of an attack of sub- 
acute mania. There were strong reasons why he should not be sent to 
an asylum, and I got a first-rate attendant for him, who kept him out in 
the open air, walking, fishing, etc., for ten hours a day. I put him on 
milk diet, with warm baths, Parrish's syrup, occasional di^aughts of 
bromide of potassium and chloral at night, and used occasional blisters to 
his head. He used often to attack his attendant fi'om delusions about 
him. who. however, never lost his nerve, and was not afi^aid of him. He 
always apologized afterwards. Gradually the excitement passed ofi", and 
in about eight months he recovered. A certain mental irresolution and 
tendency to change was the last symptom to disappear, as is the case 
commonly in mental disease. A perfect power of volition, spontaneity, 
the power to originate, is, in fact, the highest mental faculty, and is the 
last to return and the most apt to be left impaired. I could scarcely 
have believed at one time that such a patient as C. Z. A. could possibly 
or safely be treated out of an asylum. 

The second kind of maniacal homicidal attacks, viz.. that fi'om sheer 
excess of motor energy, is often seen both in acute and chronic cases. 
We had a young man, C. Z. B., in the asylum, who, when he fii'st 
became insane, attacked a man on the street, and got his own eye knocked 
out, and for many years did little by night and day but groan and shout 
in crescendo movement, box the walls so that his hands and knuckles 
were hard as horns, swollen, and often cut. He would often attack 
patients and attendants and officials violently. He was wonderfiilly 
rational amidst all this, saying he could not help it, that the steam would 
out, and that he had no desire to huit any one or any feeling of revenge 
against any one. I have now a lady who is subject to paroxysms of acute 
mania, during which she screams in an unearthly howl, tears her clothes, 
bites her own hands, and will take your hand into her mouth and bite it 
a little all round, without really hurting you, if you will allow her. 

The third form, that, namely, resulting fi'om a distinct morbid impulse 
to kill without conscious motive, I shall treat of more ftdly under 
impulsive insanity, the homicidal variety of which it is. with maniacal 
exaltation superadded. 

The fourth, or merely delirious form, is not really very dangerous, 
because it is purposeless and aimless, and the ^4olence is not coordinated. 
It seldom is seen except when delirious patients are unduly controlled. 
A physician or an attendant in an asylum generally walks up to a 



PLATE VI. 



C HART. 



Showing the numbers per iOOO of Total admissions, 
and the A^es of 996 cases of Mania, 535cases of Melancholia, 
and 104 cases of General Paralysis, making together 1635 cases 
of the 1778 Total cases admitted into the Royal Edinburgh 



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Mania 



Melancholia 

General Paralysis. 



STATES OF MENTAL EXALTATION. 165 

maniacal patient quite unconcernedly as to danger, thinking only of the 
symptoms present just as one would go in to see a case of pneumonia. 

Pkevalence of Mania. — The relative prevalence of conditions of 
mental exaltation is brought out by the fact that out of twenty-three 
hundred and seventy-seven cases admitted into the Royal Edinburgh 
Asylum in the seven years, 1874-80, thirteen hundred and ten, or fifty- 
five per cent., were classified as mania, while only seven hundred and 
twenty-nine, or thirty-six per cent., were cases of melancholia. The 
relative prevalence of the two conditions I have shown in Plate VI., 
which also shows the ages at which they prevail. Mental exaltation is 
there seen to prevail more at earlier ages than depression, and to occur 
most at two periods, viz., at the end of adolescence, and then about ten 
years afterwards. 

Insane Delusions in Mania. — The most important thing to ascertain 
about delusions in mania is whether they are '^ fixed" or fleeting. 
A fixed delusion is usually the concentrated expression of a delusional 
condition of mind. I mean that it is seldom a patient merely believes 
that a person works an electric battery to annoy him. Such a delusion 
is generally the expression of an organic or nervous sensation of discom- 
fort or pain, which makes him have his natural suspicions heightened, he 
being morbid on other points. He will not trust any one. He is apt to 
think the air of his room or his food is poisoned. If the person whom 
he believes to be working this battery goes away, he will soon fix in his 
morbid imagination the same thing on another. A patient usually not 
only believes himself to be a king, but his whole state of mind is that of 
delusive grandeur. Such fixed delusional states, that last for more than 
a few weeks in mania, are unfavorable as to prognosis ; but do not put 
down either a single delusive fancy that is repeated consistently a few 
hundred times, or a delusive condition that merely lasts a few weeks, as a 
fixed delusion. The fixity of a delusion depends on two things — the 
hold it has, whether it dominates the mental life, including other and 
natural mental acts ; and the time it has existed. Fleeting delusions are 
most typically seen in that delirium where nothing that is said has any 
relation to facts, and where no fancy or untrue statement is ever repeated 
twice. In very many cases of mania a delusion persists for a few weeks 
or longer, and yet passes away, and should not be counted a fixed delu- 
sion. There is no doubt that the less fixed and the more fleeting a 
delusion is, the better is the prognosis. 

Delusions take most various forms in mania. One of the most common 
forms is mistaking the identity of persons, calling them by wrong names, 
and recognizing old friends in persons never seen before. Certain kinds 
of insanity, such as the puerperal form, is specially characterized by this 
sort of delusion. 

Indications of Prognosis in Mania. — The following are in my 
experience favorable indications in prognosis : A sudden onset of the 
disease ; a short duration ; youth of the patient ; no fixed delusions 
or delusional conditions ; appetite for food not quite lost : no positive 
revulsion against or perversions of the food and drink appetites ; no indi- 
cation of enfeeblement of mind ; no paralysis or paresis, or marked 
affection of the pupils ; no epileptic tendency ; no complete obliteration 



166 STATES OF MENTAL EXALTATION. 

or alteration of the natural expression of the face or eyes ; the instincts 
of delicacy and cleanliness not quite lost ; no unconsciousness to the calls 
of nature ; the articulation not affected ; the disease rising to an acme and 
then showing slow and steady signs of receding; no former attacks, or 
only one or two that have recovered. 

The effect of a strong and direct hereditary predisposition is not, as is 
commonly believed, sufficient to lessen the chances of recovery, especially 
from the first attack. On the contrary, hereditary cases are often very 
curable, but relapses are more probable. A brain so predisposed is more 
readily upset by slight causes. 

The following are unfavorable indications in prognosis : A gradual and 
slow onset, as if it were an evolution of an innate bad brain tendency — 
e.g., if a naturally suspicious man has gradually become insanely and 
delusionally suspicious, or a naturally vain man has become affected with 
insane delusions of grandeur ; great length of duration of the attack, 
especially after twelve months' persistence of fixed delusions or delusional 
states ; extreme and increasing exhaustion of the patient, in spite of 
proper treatment ; paralysis of the trophic power, so that his body nutri- 
tion cannot be restored; persistent refusal of food, requiring forcible 
feeding ; extreme failure of the cardiac action and circulation, so that the 
extremities are always blue and cold ; persistent affections of the pupils, 
especialUy extreme contraction ; persistently dirty habits ; a tendency 
towards dementia : a tendency towards chronic mania ; an utter and per- 
sistent deterioration in the facial expression, especially if it be towards 
vacuity ; persistent and complete paralysis or perversion of the natural 
affection and tastes and appetites ; many former attacks ; con^Tilsive, 
paretic, paralytic, or incoordinative symptoms : such perverted sensations 
as cause patients to pick the skin, pull out the hair, bite off the nails into 
the quick ; a restoration of sleep and bodily nutrition, without in due 
time an improvement mentally ; very persistent insane masturbation ; a 
tendency for the exaltation to pass off, and fixed delusion to take its place ; 
excitation of the limbs and subsultus tendinum ; a " typhoid " condition. 

Tekmixatiox of Maxia. — There may be said to be five usual tenni- 
nations. 1. Complete recovery ; this takes place in fifty -four per cent, 
of all the cases of mania. 2. Partial recovery; the patient becoming 
rational and fit for work, but where there is a change of character or 
affection, or there is an eccentricity, or slight mental weakness, or want 
of mental inhibition, or lack of fixity of purpose, or a partial paralysis of 
the social instincts, or some inability to get on with people, or a lack or 
lessening of some mental quality which the patient possessed before. 
This is unfortunately a by no means uncommon result of an attack of any 
kind of insanity, but more especially of an attack of mania. Such 
persons count, of course, among the recoveries, and are reckoned legally 
sane. It is quite impossible to find out how many such cases there are, 
but I fear that at least one-third of all those who " recover " exhibit some 
such mental change as compared with their former sane selves. I think 
it is of the utmost importance to have the cure completed therefore, if 
possible, by prolonged medical care, by getting the whole bodily state, in 
regard to nutrition and nourishment, up to the highest possible mark 
before a patient returns to work or subjects himself to the causes of a 



STATES OF MENTAL EXALTATION. 167 

relapse. It is the existence of this condition of mental change or mental 
twist so often, and the liability to relapse, that make the public suspi- 
cious of a man who has been insane ; through which suspicion great hard- 
ship and injustice are often done to those who have already suffered from 
one of the most terrible of human diseases. 3. The substitution of fixed 
delusions or delusional states (monomania) for the exaltation as the latter 
passes oflf. It is difficult to find out statistically how often this occurs. 
The patients may live long when this takes place, except the delusional 
condition be that of morbid suspicion, in which case they will probably 
die of phthisis within a few years. 4. Dementia supervenes. This 
happens in about thirty per cent, of the cases of mania generally. It is 
the event we most dread. It is equivalent to a mental death, Avhile the 
body may live for many years, especially if the dementia has come on in 
youth. We have had many patients live so for fifty years in Morning- 
side. The bulk of the chronic patients in asylums are of this class. 5. 
Death occurs in about five per cent, of the cases from exhaustion, or from 
causes directly traceable to the disease. 

It must be understood that those are the terminations in cases of mania 
so severe as to require asylum treatment. If we could include the slighter 
cases treated at home, the recoveries would be more and the terminations 
in dementia and death fewer. 

Prophylaxis of Mania. — A v^ry important question often needs solu- 
tion by medical men in practice. There are young people growing up in 
the families they advise and attend with neurotic heredity, manifestly 
unstable brain constitution, " excitable " dispositions and nervous dia- 
thesis ; and the all-important question is asked, How can such persons 
best avoid the tendency to attacks of mania ? They have patients who 
have already had attacks of maniacal exaltation, some decided and some 
only nascent. How can such be avoided in the future ? If our present 
knowledge enabled us to answer these questions, no doubt there would 
be less insanity in the world than there is. We cannot do so surely, but 
we can do something in the direction of lessening the tendency of a brain 
to mania, I have no doubt. Beyond question, persons with this brain 
constitution should not enter on exciting and hazardous occupations. To 
take extreme examples, they should not be stockbrokers, election agents, 
or speculators. Quiet routine modes of life suit them best ; positions 
with fixed work and fixed salaries are most desirable for them. ^luch 
outdoor life, living according to rule, dividing up their day into regular 
portions for work and idleness and amusement. 

As regards diet, the same advice I gave about children predisposed to 
melancholia applies here. It should consist largely of milk and fiirina- 
ceous diet for the young. I latel}^ saAv a most excitable boy of six, very 
thin, restless, not sleeping mucli, and, of course, very bright and quick 
for his age. I found he was getting animal food three times a day, and 
his guardians deplored the fact that he could not take milk ; my advice 
was to starve him into taking it, to make him walk mucli and keep him 
out, and give him when he came in only bread and milk. Of course, it 
was disagreeable at first, but tlic boy soon acquired an appetite for such 
food, his bodily conformation largely changed, and lie got fatter, U\^s 
active, and slept far more. Children Avith this disposition are nearly 



168 siAizs or XENIAL kxaliatiox. 

always flesh-€aters. and I have sometimes found them fed on bee&teaks 
and port T\ine- with strong beef-tea between meals I I look on strong 
beef-tea «iniiik alone, without bread or potatoes, as simple poison for such 
children. I do not, of course, mean this to apply when they are dl, and 
nee<l a stimulant. Such persT'DS should take as much sleep as po^ble: 
they should cultivate quiet hobbies : they should select country occupa- 
tions, and avoid stimulants, tobacco, and sexual intercourse tiQ after 
adolescence. While ordinary well-constituted brains may stand excesses 
of all kintis. ia work and in pleasure, and may even iu a way be said to 
be sometimes the better for them, this is unquestionably not the case 
with those I am now describiog. The excess of power beyond the daily 
needs, the capacity of quick recuperation, the tendency to stop working 
and to sleep when tired, the power of being satisfied with only a slight or 
an occasional excess over what the strict laws of nature would dictate, 
which characterize healthy well-constituted brains, are all wanting in 
those predisposed to maniacal attacks. I cannot help thinking that for 
SDch persons to take to study or to occupations that imply much brain- 
work is a risk, though they have often bright iatellects. It seems to me 
as if instead of that they should go back to natme and mother earth, and 
become feimers and c-olonists. I once knew two trorhei-s. twins, alike in 
mind and body, who had a strong heredity to mania. They b<:»th 
became medic-al students, and one had an attack of acute mania at twenty, 
which ended in dementia. At the beflrinninfl^ of his brother "s anack the 
other had distinct premonitions of the same disease — ^was sleepless, 
restless, nnsetded, had queer sensations in his head, and felt as if he 
would lose lus self-control. Bni he at once fled, as for his life, from 
books and brain-work, and went to be a land-surveyor in the Far West. 
TTiR neurotic symptoms passei off. and he grew into a strong and happy 
man. I think it is the instinct of self-preservation that makes young 
men sometimes flj from the influences of civilization and take to the 
backwoods. But what about the young women ? Alas ! the prospect 
for those with sach heredity, and when th^ are well off and live in 
dties, is often lamentable. So &r as my experience and observation 
go. the r^ulated life of a c-onvent or sisterhood, or systematic religious 
and philanthropic work, fiilfils the c-onditions of prophylaxis when the 
tendency is very strong, better than anything eke. I am often profoundly 
impressed with the physiological and medico-psychological character 
of many of the observances and r^ulations of the Koman Catholic 
Church as to modes of life and outiets for the emotions. The frameis of 
these observances had often anticipated modem physiologic-al inductions. 
But supfK:»se there is not merely a predisposition, but that the actual 
prodromata of the disease are showing themselves, let us say sleeplessne^, 
want of full power of self-controL and general unsenledness. should 
medicinal hypnotic-s be taken — opium, or bromides, or chloraL or 
henbane '? I think I have seen these do more gocni as sleep-producing 
prophylactics than as curatives after the disease had actually begun. 
There is no doubt that in the maner of its rest-in-sleep p^wer. like many 
of its other factilries. the brain forms habits, and gets into bad and morbid 
as well as into gc>*'A habits. A man falls off his sleep at his regular 



STATES OF MENTAL EXALTATION. 169 

time or awakes at too early an hour, and he cannot get rid of this habit 
his brain has got or is getting into, and if allowed to go on uncorrected 
he will become exhausted and insane. Now, while I should in such 
a case invariably try first nature's simple sedatives — sea or mountain air 
breathed all day, muscular fatigue, hot drinks at bedtime, change of 
scene and work, etc. ; yet I have to aid these often by a few doses 
of chloral and the bromides, or by a grain or two of opium at night. 
Camphor and tincture of lupuline are often sufficient sedatives, or a few 
drops of tincture of belladonna, in fact any sleep-producer; but do not, 
if possible, let the brain get into the evil habit of depending on such 
drugs for sleep. 



LECTURE V. 

.STATES OF ALTEKNATION, PERIODICITY, AND RELAPSE IN 
MENTAL DISEASES {FOLIE CIRCULAIEE, PSYCHORYTHM, FOLIE 
A DOUBLE FORME, CIRCULAR INSANITY, PERIODIC 3IANIA,^ 
RECURRENT MANIA, KATATONIA). 

One of the most fundamental of the laws that govern the higher 
functions of the nervous centres in all vertebrates is that of alternation 
and periodicity of activity and inactivity. In all the higher species of 
the class the periods of inactivity are marked by unconsciousness, and 
are often combined with the mental phenomena of dreaming and muscular 
expressions or equivalents of ideation; which things are quite as strange 
and inexplicable in their essential nature as the phenomena of mental 
disease. Both may be in a general way understood by reference to men- 
talization as a brain function. Neither are in any way comprehensible 
on any mere mind theory apart from brain. The sleep and waking 
periodicity of the higher brain functions is the foundation and type of 
all the other periodicities which exist in the nervous functions, and they 
are not a few. The yearly hibernation of many animals, the daily 
periodic rises and falls of body temperature, the daily increase and 
decrease of the pulsations of the heart and of the cardiac pressure, the 
periodic returns of the appetites for food and drink, and of the activities 
of the glands and involuntary muscles through which food is digested and 
assimilated, are all examples of secondary nervous periodicities which 
occur in the course of the daily life of the organism. When we look at 
the function of reproduction of the organism, we find that every activity 
and process is subject to laws of periodicity of the most marked character ; 
and there can be no doubt that these all have their origin in the brain. 
The period of reproductive activity is always, in both sexes, the period 
of greatest physiological mental exaltation. The periodic rutting season 
in male animals, with its courage, pride, activity, display, pugnacity, and 
restlessness ; the young-bearing and suckling period in females, with its 
increased courage, skill, cunning, protective and providing instincts, show 
how the functions of the brain are afiected by the reproductive perio- 
dicity. So much are they affected that the mental characteristics of some 
animals are completely changed from their natural condition and reversed, 
the timid becoming bold and the shy obtrusive ; hereditary and natural 
antipathies and fears disappear for the time, the habits change, night- 
feeders become day-feeders, etc. We should not approach the study of 
the periodicity of symptoms in nervous and mental diseases without 
keeping in mind these laws and facts of the physiological periodicity of 
normal nerve function wherever we have a higher nervous system. 

Looking at the mental activities of human beings, we find them 



STATES OF MENTAL ALTERNATION. 171 

strongly influenced by the physiological periodicities. What man is there 
who is not emotionally more elevated or depressed, more active or inac- 
tive in mind, at certain times, or at his periods of almost regularly re- 
curring reproductive desire and capacity ? What woman is exactly the 
same in mind before, during, and after menstruation, and during preg- 
nancy or lactation ? And the instant we pass from absolutely healthy 
brains, all those periodicities count for more in the mental life, their 
efiect in dulling, elevating, and depressing being far greater. There are 
thousands of sane men and women who are regularly duller in the morn- 
ing and more lively in the evening, or the reverse ; or who are duller in 
the winter and more elevated in the summer ; or who are more irritable — 
that is, have diminished inhibitory power — at periodic intervals, or who 
are subject to "moods" and "tempers" periodically. There are many 
persons whose mental life is one long alternation of "action" and "re- 
action," activity and torpor, by a natural law of their organization. 
When we look at diseases of the nervous system other than the mental, 
we find that many of them are often markedly periodic in their symptoms 
and times of recurrence. I need only instance neuralgia, migraine, and, 
above all, epilepsy, that motor analogue of many mental diseases. 

Two French writers, Falret and Baillarger, were the first to describe 
as a special form of insanity certain cases in which there are regularly 
alternating and recurring periods of mental exaltation, depression, and 
sanity, and to call it folie circulaire. Each of these periods may vary 
in absolute duration from a day to several years, and in relative duration 
to the other conditions in the circuit in different cases ; but they always 
recur and follow each other with more or less regularity. In some the 
period of exaltation is long and the depression and sanity short; in 
others this is reversed. But in the really typical case the periods are 
each about the same length in each psychological circle, and the recur- 
ring circles all about the same size. Usually there is something special 
about the exaltation and depression. The exaltation is very pure brain 
exaltation, with often hypersesthesia and exaltation of many of the ner- 
vous functions, with much reasoning power left, but little self-control or 
common sense ; the condition described by the French as folie rxdsson- 
nante, or Pritchard's moral insanity, being well marked at the early 
stage. There is in nearly all the cases great increase of the reproduc- 
tive nisus. The phases of the exaltation, down even to small things, 
recur regularly in different attacks at the same time. The depression is 
apt to be characterized by apathy and torpor rather than by intense 
mental pain : there are seldom any strong suicidal feelings or impulses. 
And the period of sanity is apt to be a sort of stupid, inactive sanity, 
wanting in volitional power, full affectiveness, and spontaneity. The 
mental balance goes on oscillating between melancholia and mania, 
standing still at the happy mean of apparent sanity just long enougli to 
raise hopes that recovery has taken place for a few times, till the nature 
of the disease is apparent to the pliysician, and as often as they occur to 
ever-hoping relatives. It is mostly an incurable disease, and the bad 
cases are usually sent to asylums rather than treated at home. 

The interest of this form of mental disease is small when it is merely 
looked at as a rare psychosis of typical form : but it is very great indeed 



172 STATES OF MENTAL ALTERNATION". 

to the student of psychiatry when, in the first place, we make it a means 
of studying the clinical differences in the whole brain and body state of 
the same patient in exaltation, depression, and sanity respectively; and 
when, in the second place, we look on it as a pathological illustration of 
the great physiological periodicities to which I have referred, and of the 
almost constant tendency there is in nearly all cases of insanity, or at 
least in most of those that are hereditary, towards relapse, alternation, 
periodicity, or sympathy with exalted physiological function. 

The following are some illustrative cases : 

D. A., aet. 49 on admission to asylum. He had never been placed in 
a hospital for the insane before, though he had had from his boyhood 
dull times and active times, and many slighter attacks of the kind I am 
about to describe for five or six years previous to his admission. In one 
of the periods of exaltation, while holding an important position in India, 
he had got two tiger cubs, and tried to drive them in harness through the 
streets of the Residency. His education was good, his temperament 
sanguine. He had been reckoned proud and retiring, and he was of an 
old and distinguished family. In bodily conformation, carriage, and 
bearing he was the type of an aristocrat. A paternal uncle, at least, 
had been insane, and had shown periodicity. His family had been a 
very artistic one, but he had never, when sane, shown any talent in that 
way. He had married and had children. 

Just before admission he had been spending money recklessly, pro- 
posing marriage to many suitable and unsuitable persons, getting into 
passions and using threats about trifles, reckless, eccentric, changeful as 
the winds in intention and execution. The attack was coming on, but 
had not come to a height till a week after a domestic loss. 

When admitted he was much excited and very indignant, calling on 
all to witness that he was illegally imprisoned, threatening the dire 
vengeance of the law on all who had to do with it, but in about ten min- 
utes he was quite jolly, and amusing himself with a game of billiards. 
At first he was exalted mentally, but had much self-control. His ex- 
citement consisted in a constant restlessness, a perpetual twisting move- 
ment and play of his facial muscles. He could not sit still, or read, or 
engage in a game for long. He talked much, but could not stick to one 
subject ; he was boastful in a way that was to him unnatural ; he spoke 
of his private affairs, and would indulge in very pointed questions and 
remarks, without much regard to your feelings. To a good billiard- 
player, "I'll give you fifty points, and bet a pair of gloves I'll beat you. 
I don't want to hurt your feelings, but I suppose you know your style of 
play is not very fine." To a man who had been in trade, "What do you 

think of my stockings, Mr. ? That was in your line." He was 

often extremely amusing, fluent, and witty, which he had never been 
when well. He would rattle off Scotch to the pauper patients in the 
grounds, French to the ladies, and Hisdustani to himself in a way he 
could never do when sane. In dress he was untidy, and in habits dirty. 
To the ladies, of whose society he was extremely fond, he was exagger- 
atedly polite, with the grand air of the olden time ; but if they gave him 
any encouragement he would soon become too familiar. He was always 
giving them flowers, which he had stolen, and writing them notes, or 



STATES OF MENTAL ALTERNATION. 173 

trying to kiss the maid-servants. If he had any request to make from a 
lady in the drawing-room, it was no uncommon thing for him to go down 
on one knee, with his hand to his heart, and all this done most gracefully 
and amusingly, as if half in fun and much in earnest. 

He smoked as much as he could get, and was always grumbling he did 
not get cigars and tobacco enough, and begging, borrowing, or stealing 
more. He ate enormously, but not nicely, of everything that came in 
his way. He picked up and appropriated everything belonging to others 
that he had a fancy for, and did this also most gracefully, as if it was 
the most natural thing in the world. He was irritable when controlled, 
contradicted, or refused requests, and he was always making innumerable 
and impossible requests. He slept badly, and would, if allowed, sit up 
all night, or get up and move about by three or four o'clock in the 
morning. He was not susceptible to cold, sitting with all his w^indows 
open in winter. 

He passed gradually out of one stage into another. The next stage 
was a more maniacal one. He dressed more grotesquely, and always 
wanted to put on three or four coats, vests, or trousers on the top of each 
other. He would come in to a dance with four vests, would go behind a 
door or another man, and slip one and then another off as he got warm. 
His habits and ways got more dirty and disorderly. His irritability took 
violent forms, assaulting his attendants, smashing furniture, etc. His 
conduct became so uncontrolled that he could not go to the drawing-room 
or to church. He would run after a petticoat without regard to the ap- 
pearance or age of its wearer. His whole tastes as to food were the op- 
posite to what .they were in health. He liked porridge, which he 
could not abide when well, and if he did not feel inclined to take it, he 
would turn it out on to his newspaper, put it in his pocket, and eat it 
when he felt hungry. He would mix up soup, milk, and claret, and eat 
them together. Scarcely anything was incongruous or disgusting to him. 
He wore his hair very short, and would singe it or cut it himself if he 
could get no one else to do it. He would, in playing cricket, strip him- 
self almost naked, or put on the most ridiculous things, a woman's hat 
or shawl, or a cap turned outside in. He turned up at morning prayers 
one day in buckskin tights, a red vest, a blue cap, and black swallow-tail. 
His bowels were always moved twice or thrice a day. During all this 
time he was losing or tending to lose weight is spite of all he ate. He 
had his better and worse days all through, usually in alternation. He 
used to paint and draw pictures and portraits at this stage, producing 
the vilest daubs, spitting on the paper to moisten his colors, and using 
his hand and fingers to spread his paints. These he would carry in his 
pocket by the dozen, showing them to any one he met — and he could 
pass no one without speaking. He said he had never known he could 
paint before. So with singing : he would sing in discord, and think he 
was doing splendidly. Yet with all this there never left him a certain 
jauntiness and grace of manner. No one, at his worst, could liavc taken 
him for anybody but a high-bred gentleman. 

As this brain exaltation caine on and increased in every successive 
attack, each little phase, each little morbid way, such as smoking, eating 
certain kinds of food, cutting or singeing liis hair and beard, painting. 



174 STATES OF MENTAL ALTERNATION. 

putting on one coat on the top of another, would recur with the regu- 
larity of the bud, leaf, and fruit of a tree. 

The next stage was the gradual subsidence of all these S3''mptoms of 
maniacal exaltation, and a resumption of his former habits and ways and 
appearance. 

The first stage, corresponding to simple mania, lasted for about a 
month ; the second, w4th the symptoms of mild acute mania, about two 
months, and his recovering stage about three months, so that the whole 
period of exaltation lasted six months ; but he did not stop at the sane 
stage. He at once passed into a condition of great mental depression. 
To see him in that, one would scarcely have known him to be the same 
man. His hair well grown, his whiskers trim, his features and eyes dull 
and inexpressive, his dress most scrupulous and neat, his manner distant 
and nervous ; in speech reticent, and never venturing a remark ; in feel- 
ing depressed, fearful, and unreliant. He thought he was so wicked 
that he should not see any one. He now disliked most of the people he 
had cultivated during his exaltation, especially relying on the chief at- 
tendant, who had controlled him most, and whom he had most heartily 
abused. His habits were sedentary, he could scarcely be got to go for a 
walk ; his appetite was now moderate, and his tastes very particular, not 
being able to bear the smell of tobacco or to look at porridge or messes 
of any kind, and most sensitive to dirt and bad smells. He became very 
penurious about money. He was always thinking he was doing wrong 
or giving oifence, and did not- like company, while he was most moral 
and religious in his feelings and habits. His whole intellectual and aifec- 
tive life was far more unlike his exalted self than one average man is 
unlike another. He was stationary in weight at first, but soon began to 
o-ain. He was most sensitive to cold and drauo-hts and loud noises, in all 
of which he had delighted before. He was full of a morbid sorrow and 
regret for his previous conduct ; but he was morbidly suspicious at this 
stage, and used to think that the things he had given away or destroyed 
during his excitement had been stolen. This condition lasted for about 
three months, gradually passing into one of complete sanity, without de- 
pression or elevation, but with some inertness at first, and without much 
capacity for business. This lasted about six months, and then the signs 
of elevation again began. Altogether this circle of elevation, depression, 
and sanity lasted about fifteen months. There was no marked line any- 
where, though the most distinct and sudden transition was betAveen the 
elevation and the depression. 

The development of the exaltation next time was a slow process, taking 
about two months before it got so bad that he had to come back to the 
asylum. The sort of things he did were going out to ride at 10 o'clock p.m., 
never going to bed, smoking all the time, foolishly wasting his money, 
proposing to marry ladies and women suitable and unsuitable, sometimes 
two in a day, telling one, as an inducement to accept him, that if she 
would marry him she could put him into an asylum and enjoy his pen- 
sion I He went into a shop to buy a pair of gloves, and the shop-girl 
taking his fancy, he went down on his knees to her, telling her he had 
fallen in love with her. His nisus generativus was always exalted during 
the excitement, but seldom assumed very gross forms. He often said 



STATES OF MENTAL ALTERNATION. 175 

that if he could be castrated he would be cured. The great difficulty at 
this stage was to get " facts" indicating insanity to put in the medical 
certificates for his admission to an asylum, for he was very acute, and 
knew what a doctor's visit meant quite well ! 

In the second circle of his disease after coming to the asylum, all the 
symptoms were similar to the first, and developed themselves in the same 
order. The excitement was more acutely maniacal than it ever was before 
or has been since. The whole period of elevation lasted a year this time, 
of depression six months, and sanity six months, the circle taking two 
years to get through. 

The third circle had a period of excitement of ten months, of depres- 
sion of six months, and of eight months of sanity — in all, two years. 
The fourth circle had a period of excitement of thirteen months, of de- 
pression of about six months, and of sanity of fourteen months — in all, 
two years and nine months. He was out of the asylum, living at home, 
for a year and eight months during part of the depression, the whole 
period of sanity, and the first month of the commencement of the ex- 
citement. He did not enjoy the society of his relations during the de- 
pression, and they said he would have been better to have been in the 
asylum ; and at the beginning of the excitement, when they had to re- 
monstrate with or control him, his affection for them ceased, and he got 
on worse with them than in the asylum with strangers. He said cruel 
and unkind things to them. 

In the fifth alternation the excitement lasted two years, the depression 
twelve months, and the sanity fifteen months — the whole thus taking four 
years and three months. He is now in the twenty-third month of the 
exalted stage of the sixth circle, with the usual symptoms, but none of 
them are so severe as they were on previous occasions. It seems as if, 
at sixty-tw^o, his brain was not capable of taking on so acute an attack 
of excitement, the nisus generativus not being so keen. He is now 
capable of being sooner tired, and takes rest, which he never did before, 
and the diurnal changes are very marked. He has one good and then a 
bad day. But the outward eroticism, the alertness and grace of move- 
ment, the kleptomaniacal tendencies, and all the small phases of his ex- 
altation are still there, there being no trace of the mental enfeeblement 
of dementia, of bodily exhaustion, or of chronic mania. The damage 
done to the organ by the previous attacks of exalted morbid energizing 
has evidently been repaired in the intervals of sanity, during which he 
lays on flesh greatly. The bromide of potassium alone and combined 
with cannabis indica did not influence any of the attacks of excitement. 

The following is the record of a case of most prolonged, and, on the 
whole, one of the most regularly alternating cases of folie circulaire in 
short circles I have ever seen : 

D. B., get. 30, was admitted to the Royal Edinburgh Asylum in 1847 
without any history whatever ; but she was a person of education and 
intelligence, though sent as a pauper patient. She labored under all the 
symptoms of acute mania at first, and in a few days it was recorded that 
she was "imbecile," then in a few days more that she was quite well. 
Since that time till noAV — for thirty-six years — she has had regularly 
recurring short attacks of acute mania, during wliicli she is restless. 



176 STATES OF MENTAL ALTERNATION. 

incoherent, excited, destructive to her clothing, violent, and with no 
memory or consciousness of familiar things or persons, this lasting from 
a week to four weeks usually. This is succeeded by a few days of a con- 
dition with all the symptoms of dementia with a little depression, and she 
then becomes practically sane for a period of from a fortnight to eight 
weeks. Her circle takes from four to twelve weeks to complete, enfeeble- 
ment of mind taking the place of the more usual depression. We have 
a wonderfully complete record of her symptoms all these thirty-five years ; 
and though once or twice there are such entries as " She is now almost 
continuously excited," as in 1852 for a month or so, or "Periods of 
excitement more frequent, of quiet shorter," as in 1853 and in 1861, 
"InterA^als of quiet longer," as in 1862, yet the irregularities are no 
greater than are common in regard to menstruation in the average 
woman. There can be no doubt that this is an example of mental 
alternations governed in their times of occurrence and duration by the 
menstrual periodicity. For long she had amenorrhoea, but the return of 
the catamenia made no difference, and, more strange, the ceasing of men- 
struation at the climacteric made no difference. Now, at sixty-six, the 
regular alternations of acute exaltation, mild stupor, and sanity are not 
so regular as before, and the symptoms of the exaltation are scarcely so 
acutely maniacal as at first. The whole case is otherwise instructive, for 
though it shows the known tendency in a brain for acute excitement to 
exhaust and destroy the normal power of energizing of the convolutions 
and leave that diseased mentalization which we call dementia, it also 
shows this, that even severe attacks, when short, produce only a short 
enfeeblement, which is recovered from soon. Most instructively of all, it 
shows that over two hundred of such attacks, continued for such an 
enormously long period as thirty-six years, need not necessarily destroy 
the mental power of the brain and produce complete and permanent 
dementia". The brain in this proves the recuperative and resistive power 
that it shows in many other ways, if the periods of the exalted energizing, 
or the strain, or the poisoning, or the morbidness is only short in time, 
and the organ gets rest between one attack and the next. We all know 
that periodic sprees may be continued with impunity in many people for 
a lifetime, and that many men may safely work their brains at full 
pressure for many years if they give them a Sunday rest and an annual 
holiday. 

I had another case, a lady, D. C, who was for ten years in the asylum, 
who took attacks of excitement lasting about a fortnight alternating with 
periods of depression for a week, but in her case, as in that of D. B., the 
depression immediately preceded the excitement, and the periods of 
sanity were about three weeks in duration. But, like all the rest of the 
cases, the length of the periods of the different conditions was not abso- 
lutely uniform. In her case, also, the regular alternations went on up to 
the age of seventy-eight, when she died; occurring only in a mild form 
during the last six months of her life, when she had a broken leg, an 
ulcerated and sloughing ankle, and was very exhausted. But her mind 
was rather enfeebled during the quiet "sane" periods for the last ten 
years of her life, and she had sexual delusions about men wanting to 
seduce and marry her. The exhausting effects of the excitement on her 



STATES OF MENTAL ALTERNATION. 177 

brain, as in many of the alternating cases, were aggravated by her 
addiction to masturbation during the exalted periods. 

I have now under my care a gentleman, D. D., aged 49, who for the 
past twenty-six years has been subject to the most regularly recurring 
brain exaltation every four weeks almost to a day. It sometimes passes 
off without becoming acutely maniacal or even showing itself in outward 
acts ; at other times it becomes so, and lasts for periods of from one to 
four weeks. It is always preceded by an uncomfortable feeling in the 
head and pain in the back, a mental hebetude and slight depression. 
The nisus generativus is greatly increased, and he says that if in that 
condition he has full and free seminal emission during sleep the excite- 
ment passes off; if not, it goes on. Full doses of the bromide and 
iodide of potassium have the effect sometimes, but not always, of 
stopping the excitement, and a very long walk will at times do the same. 
When the exaltation gets to a height it is followed always by about 
a week of stupid depression. It seems as if the depression in those 
cases always meant a reaction after morbid over-action — a muddy mental 
calm after a storm, an anaesthesia after a hypersesthesia. 

In the following case the alternations began in old age : D. C, 
ast. 74 on admission, unmarried, has had several attacks of excitement in 
the three years previously. A sister is insane, and brother hemiplegic 
with periodic attacks of mild mental exaltation, which also came on in 
advanced life. But the patient had been a staid, industrious man, who 
had been in business all his life, and done his work well till he was over 
seventy, leading a sober life. He has been excited for three months. 
It began first by great mental exaltation and hilarity of manner. He 
was very fond of the ladies, but never erotic. Especially he used to 
laugh most immoderately at nothing in particular, putting down his 
stick into the ground, and bending forward and roaring with laughter 
from five to ten minutes running. This had exactly the effect of a man 
laughing well and continuously on the stage, at a cause of which you are 
ignorant ; it was catching, and you could not help laughing too. This 
gradually passed into a stage of violence, delusions of insults, shoirting, 
sleeplessness, and suspicion. During the exalted period his temperature 
was always over 99°, he ate enormously, craved stimulants, his bowels 
were moved twice a day, and he slept little. His conduct was extremely 
ridiculous for an old man. His delusions were mere fleeting fancies and 
suspicions. In four months from the beginning of his attack he became 
depressed, and then he never spoke, looked dull and heavy, slept well, 
and got fat, but his bowels became very costive. All his brightness and 
curiosity and much of his intelligence left him. He took no interest in 
anything. There was much of stupor in his state. He felt little mental 
pain. After about two months he got over his dulness, and became 
practically sane, cheerful, chatty, and contended. After three months of 
this condition, or about nine months from the beginning of the attack, he 
gradually got exalted, and passed through exactly the same phases 
as before. One never gets pure mental exaltation so well as in a good 
case of alternating insanity. The excitemont lasted about six mouths, 
from March to December, being very mild for the last throe nu>nths ; he 
then passed into a two months' attack of stupid depression as before, and 



178 STATES OF MENTAL ALTEENATION. 

was then fourteen months well, his whole circle thus taking twenty-two 
months to complete. He next got exalted in December, and was acutely 
excited for about three weeks only, and then had an attack of extreme 
stupor, depression, weakness, and prostration for three months. He then 
became sane; but almost at once passed into another attack of excitement. 
The whole duration of this circle was only four months. The excite- 
ment that followed was more acute than it had ever been before ; it lasted 
five months, and was followed at once by great depression lasting six 
months. He was then sane for three months, this circle taking fourteen 
months to complete. This time he became exalted in May, and Mr. 
Geoghegan, the assistant physician in charge, thus describes him: "Mr. 
D. C. is abnormally excited and emotional. When in good humor he is 
ridiculously polite, tells the most pointless story over and over again, 
laughs louder and harder at it each time it is told, till the tears run 
down his cheek? and he has to hold on to some object to prevent him from 
falling ; and his listeners, by pure contagion, are in much the same con- 
dition. At other times his conversation is absurdly religious, and he 
overdoes the part of a sanctimonious revivalist; and if his hearers show 
any Avant of gravity — a hard thing to avoid — he gets passionately indig- 
nant, and after a storm of displeasure goes off in high dudgeon. He can 
never bear contradiction or difference of opinion without anger." This 
circle took twenty-one months to complete. In December he became 
exalted again, his irritability being very great this time, and his hilarious 
happiness less marked. He remained so for nine months, and then 
became depressed rather suddenly, passing into a condition of almost 
complete stupor, and leading an almost vegetative life. He remained so 
for almost five weeks, and then, without the usual intermediate period of 
sanity, he suddenly one night became delirious Avith hallucinations of sight, 
but this only lasted for one day. He was then four days depressed, and 
again got exalted, with more decided delusions than he had ever had 
before. This lasted less than two months, and he then went into 
an attack of stupor again. By this time he was eighty-two years of age, 
and he had an epithelioma of one of his great toes, with irritation and 
suppuration, which acted as a drain and an irritant. This toe was ampu- 
tated by Mr. Bell, and he made a good recovery, and he gained in flesh 
and strength, but has remained in the condition of depressed partial 
stupor ever since for three years, lying in bed mostly. He will answer 
questions when spoken to, but never ventures a remark or takes any 
notice of anything. He is in a state of complete senility and mental 
torpor. 

In this case, as in most of the others that I have seen with prolonged 
alternations, they were irregular ; but in him the periods of excitement 
always began in cold weather, from October to May. The most striking 
circumstance about the case is its commencement at seventy-four, after 
the intensity of the sexual period of life was past. It is only the second 
case of that kind I have known. The excitement coming on in spurts 
for a few days at the last, as if the senile brain had no longer vigor 
enough to keep up a prolonged exaltation, would seem to be the natural 
ending of alternating insanity, whether it terminates in mild or complete 
senility, or in dementia. 



STATES OF MENTAL ALTERNATION. 179 

In the following case of D. B., the attacks of excitement and those of 
depression ceased at the age of sixty-five, after alternations of the two 
had lasted for twenty years. He was an artist, but could only paint at 
the beginning of the period of exaltation and at the end of it. He 
never could finish a picture, and if he attempted to do so he got worse 
mentally. So long as painting was spontaneous or pleasurable he did it, 
and it did him no harm. If he could not catch a likeness, or tried 
to elaborate or paint in details, or had nothing but drudgery to do, he got 
worse. In his case there was most marked exaltation of the memory, and 
his fancies always took the pleasant form of a loss of his own personal 
identity and the assumption of that of the author whose works he was 
reading or repeating. As he got better he would tell me that he was very 
happy indeed as he lay awake at nights, for he would fancy he was 
Shakespeare, Burns, or King David, as he repeated aloud their works. 
He could vividly recall the events of his boyhood, and repeat long con- 
versations he had held with his friends then. His eyesight and hearing 
became very acute, so that he could read small print, and paint without 
spectacles, and hear whispers ; w^hile as the exaltation wore off he had to 
use stronger and stronger spectacles, and was very deaf. When depressed, 
all his bodily functions, appetites, and propensities were torpid and 
sluggish. There was a difference of 2.2° betAveen his average temperature 
during exaltation and depression. ' There is in the case-books of the 
Carlisle Asylum a careful record of his condition from 1862 till his death 
in 1876. Mt. 54, 1862, January, exalted ; July, pretty well : 1863, 
July, quite well ; October, depressed : 1864, February, exalted ; July, 
depressed ; October, quite well : 1865, April, depressed ; August, 
exalted: 1856, January, quite well, and remained so till 1867, when in 
July he got depressed, and in December his alternations were diurnal, he 
being one day depressed and the next very excited, this lasting for a 
month or two: 1868, July, became depressed; October, quite well: 
1869, April, depressed, and was so till October, when, instead of the 
usual and expected exaltation, he got quite well, and kept so for over 
three years, till January, 1873, when he had a short attack of mild 
exaltation, lasting for three months. He then kept well till January, 
1874, when he had a few occasional days of slight excitement at irregular 
intervals, and then got quite calm and rational, though not energetic — in 
fact, he got into the typical and normal senile condition of mind and body, 
his brain remaining in this quiet haven of rest, after its twenty years of 
violent alternations of storm and sluggishness, till he died of bronchitis 
in the end of 1876, at sixty-eight. In this case it will be observed that 
there was a distinct tendency for the periods of exaltation to occur in 
the early part of the year, in January and February, and the periods of 
depression to come on toAvards the end of the year, from October to 
December. The periods of depression did not follow, but precede, the 
exaltation in this case, contrary to the usual experience. One should 
perhaps say that the excitement followed, and seemed to be a reaction 
from the depression. 

The following dates of the admission and discharge of D. I. show the 
length of the attacks in his case, for he is sent to the asylum whenever he 
gets exalted, and is sent home wlien the excitement passes oft', lie is then 



180 STATES OF MENTAL ALTERXATIOX. 

not very painfallv depressed, quiet, penurious, and unsocial, sluggish for 
two or three months, and then gets quite sane and does his business very 
well. His exaltation is of the typical kind, talkative, energetic, passionate, 
quarrelsome, abusive, restless, sleepless, but never incoherent, and very 
fond of spending his money lavishly. He once got off to London about 
the beginning of an attack with £1000 in his pocket, with the deliberate 
intention to spend it in a month and enjoy himself, as he said he had "led 
too quiet a life at home," and he pretty nearly got through it. I have 
reason to believe that he once made a large sum of money during one of 
his exalted brilliant periods, just as he was passing into the elevated part 
of a morbid mental circle. Hopefulness, superabundant energy, mental 
subtility, argumentativeness, wildness, a strong leaning towards the other 
sex, but not an offensive eroticism, characterize this period. The dates 
show the irregularity of the seasons at which the attack came on, and of 
their duration. He was forty-five when first admitted, and had had a few 
attacks previously. Admitted October, 1866, discharged January, 186T ; 
admitted April, 18T0, discharged May, 1870 ; admitted August, 1871, 
discharged September, 1871 : admitted December, 1872. discharged 
February, 1873; admitted February, 1875, discharged May, 1875: 
admitted August, 1877, discharged September, 1877; admitted Novem- 
ber, 1880, discharged January, 1881: admitted December, 1881, 
discharged March, 1882. 

An examination of the exact periods during which the exaltation, 
depression, and sanity persist, their relation to each other during 
different recurrences, and the sizes and regularity of the successive 
circles in each case, shows this far more than I had supposed previously 
to more exact investigation, viz., that the periods are not always the same 
in the same patient at different times, and that, in fact, very few of them 
are regular and typical in theii' symptoms. I only find about one or two 
out of forty cases of folie circulaire that were absolutely regular. In 
others the periods of excitement were often twice as long in one circle as 
in another, and the periods of depression and sanity varied also. The 
age, state of the general health, conditions of life, critical periods, diet, 
medicines such as combination of the bromides and Indian hemp, have 
all the power of modifying the length and the intensity of the periods of 
exaltation particularly. We shall see how important those facts are, 
taken in conjunction with the views as to the essential nature of those 
alternations which I am to speak of. 

While a typical case of alternating insanity is not hopeful, yet, in 
prognosis, we must not conclude that a case is incurable merely because 
there are recurrences and alternations for a few months or for a year, or 
even for two or three years. 

It is very interesting and most important to study minutely the ex- 
act psychological differences in the same brain when morbidly elevated, 
and depressed, and sane : and it is almost equally important to compare 
the differences in the bodily symptoms of the two former conditions. 
The cases I have recorded show many of these differences and symptoms. 
In the elevated stage, either at the beginning or all through it, there is 
an actual exaltation of many of the mental faculties, notably of memory, 
of general acuteness and ability to reason, in a way. The mentalization 



STATES OF MENTAL ALTERNATION. 181 

is almost unceasing in some form ; the common-sense is gone ; the power 
of self-control and of undertaking definite mental work is gone ; the 
power of attention, while it may be very acute in some ways, is not under 
the control of volition ; there is a childishness of mental condition in 
some respects, a foolish credulity ; afiectively the patient, though he feels 
morbidly happy, yet his emotions are always shallow and directed in fits 
and starts only towards objects and persons that are present, and they 
are always weakened towards or withdrawn from their natural objects, 
wife, children, etc. There is a most remarkable change in the appetites, 
which are usually quite perverted from what was natural to the patient. 
Different kinds of food, drink, and stimulants are sought for and enjoyed. 
The general feeling of hien-etre is exaggerated. The courage is exag- 
gerated, and there is little timidity left. There is an intense desire to 
attract attention. There are always extravagance and morbid generosity. 
The social instincts are enlarged, lowered in tone, and they become some- 
what promiscuous, a man nearly always seeking the company of his in- 
feriors in station. 

In the stage of depression the natural affections towards children 
usually return or flow into their natural channels with much force, but 
the subjective feeling of the patient is one of misery and ill-being : he 
has no courage, no power to resolve, no general activity of mind. In all 
the typical cases there is a sort of torpor and inactivity of mind ; there 
is niggardliness in money-spending, in wearing clothes, etc. There is 
often a feeling of profound disgust and regret at the extravagant, foolish 
acts of the excited period. 

The changes in the bodily symptoms are very marked. The patient, 
when exalted, loses weight ; when depressed he gains weight ; the differ- 
ence in weight between the two periods being often two stones. When 
excited he takes much exercise, is restless, and never tires. When de- 
pressed he is sluggish, and dislikes exercise, and is soon tired. In the 
former stage his temperature is above the normal, especially in the even- 
ing; in the latter below it, the average difference being 1.1°, and in 
some individual cases 3.6°. In the former he can bear cold well, and 
likes it ; in the latter he cannot bear cold, and dislikes it much. In the 
former his bowels are very regular, and often moved more than once a 
day ; in the latter they are costive. In the former his face is mobile and 
expressive, and his eyes glistening ; in the la,tter they are heavy. In the 
former he is always hungry, and his capacity for eating and digesting 
everything almost unlimited ; in the latter he may eat Avell, but is very 
particular as to food. In the former he craves stimulants and tobacco : 
in the latter he often loathes them. In the former he is not sensitive to 
disagreeable odors, sounds, and sights ; in the latter he is usually liyper- 
sensitive. In the former tlie skin is moist and perspiring ; in the latter 
it is usually dry and often hard, and skin diseases, such as psoriasis, not 
infrequently appear. Wliile exalted, the patient's pulse is usually full 
and hard ; while depressed, small and compressible. In the former the 
sexual appetites and capacity are always increased ; in the latter they are 
often paralyzed. (One gentleman told me that for two years he luul no 
sexual feeling or power.) The sight and hearing are often much more 



182 STATES OF MENTAL ALTERXATIOX. 

acute in the former than in the latter. In the former state the patient 
sleeps little and lightl}^ ; in the latter long and soundly. 

Many ordinary nervous symptoms follow the periodicity and alterna- 
tion of the mental. I had one T\oman whose circle took about six weeks 
to complete, and whose period of elevation was always preceded and 
ushered in by severe cephalalgia and then by vomiting. I have had 
several women in whom the depressed period was preceded by neuralgia. 
Several of my patients can tell beforehand when they are going to get 
excited, by their bodily feelings. One form of alternation has been 
called Katatonia by Kahlbaum. It is an alternating insanity, in which 
there are either epileptiform symptoms or those resembling catalepsy, 
hallucinations of sight and hearing, unconsciousness, with trophic symp- 
toms, such as oedema and weak pulse, these preceding or accompanying 
the melancholic stage. It is simply a variety of the disease in which the 
functions of the motor and trophic centres are specially involved. 

I have for a long time been impressed with the relationship of the 
mental and bodily alternations and periodicity in insanity to the great 
physiological alternations and periodicities, and I have gradually been 
led to the conclusion that they are the same in all essential respects, and 
only differ in degrees of intensity or duration. By far the majority of 
the cases in women follow the law of the menstrual and sexual period- 
icity; the majority of the cases in men follow the law of the more irregu- 
lar periodicity of the 7iisiis generativus in that sex. Many of the cases 
in both sexes follow the seasonal periodicity, which perhaps in man is 
merely a reversion to the seasonal generative activities of the majority of 
the lower animals 

A careful clinical study of mental diseases reveals the fact that there 
exists in by far the majority of all the acute cases, at some time or other, 
in some form or degree, in the course of the disease, a tendency to alter- 
nation, periodicity of symptoms, remissions, or recurring relapses. I 
have taken the 338 cases of mental disease admitted to Morningside 
Asylum in 1881 — 181 of them being cases of mania, and 129 of melan- 
cholia, the rest being general paralysis, dementia, etc. — and I find that 
in 81 of the female cases, or 46 per cent, in that sex, and in 67 of the 
men, or 40 per cent, of that sex, there was relapse, alternation, or 
periodicity of symptoms in the course of their attacks. Many of the 
338 admissions were chronic on admission, so that of the recent cases the 
decided majority showed those symptoms. 50 of the 129 cases of 
melancholia, or 39 per cent., and 98 of the 181 cases of mania, or 54 
per cent., were alternating or relapsing, or showed diurnal, or monthly, 
or seasonal, or sexual periodicity. It may therefore be concluded that 
insanity in the female sex has more of this character than in men, and 
that the cases of mania have it to a greater degree than those of melan- 
cholia. In some patients it was a morning aggravation and evening im- 
provement, those being usually cases of melancholia : in a few it was an 
evening aggravation, those being, contradictorily, also cases of melan- 
cholia. Very many cases of mania were more exalted one day and less 
so the next ; many sleeping and waking on alternate nights, these being 
usually cases of mania. The attendants are very strong on this point of 
the ''good" and "bad days" of these patients, and calculate much on 



STATES OF MENTAL ALTERNATION. 183 

them. Many of the cases had remissions and relapses of a few days 
regularly for a time. Some had monthly or menstrual aggravations. In 
some cases these periodic remissions occurred most at the beginning of 
the attack, but in far more cases towards the end of it, and during the 
convalescence of the patient. I had a lady lately under my care, con- 
valescing from acute mania — E. K., a strong, healthy woman of 38, 
who had recently recovered from a bad attack of rheumatic arthritis. 
First attack, duration ten days. Heredity to insanity. She remained 
in a state of acute excitement for about a week after admission, getting, 
however, at intervals sufficient sleep and sufficient nourishment. An 
abatement of the disease then set in, and from that period there was a 
slow but steady improvement until seven weeks after admission, when 
she was discharged, having made an excellent recovery. The most 
striking feature in the case, during the latter weeks of its course, was 
the distinct daily morning exacerbation and evening remission. Each 
morning showed a distinct improvement on the previous morning, but a 
distinct relapse as compared with the previous evening, while each evening 
she appeared to be further on the road to recovery than she was the 
evening before. In the morning she Avould be full of doubts, suspicions, 
and querulousness, while the evening would find her sensible, cheerful, 
and grateful. The change would come on in a few minutes without 
external cause. Even when convalescence was well advanced, the morn- 
ing was for her a period of distress and distrust, but with the evening 
came quiet, rest, and a thankful heart. 

Such a case is merely a type of what is very common during all forms 
of mental disease, especially during convalescence. A medical man in 
attendance should always prepare the minds of relatives for this tendency 
to relapse and alternate. Nothing is more discouraging to both the 
doctor and the relations, when it persists for a long time ; but it is our 
duty to keep up their hopes and ours, and to think of and refer to 
examples where the tendency has been quite got over, even after a long 
time. I once had a young man of twenty who took regular relapses for 
five years, and after that made an admirable recovery, and to my own 
knowledge has done his work well and has kept well for ten years. 
Taking the chronic incurable cases now in the Asylum, I find that about 
forty per cent, of them are subject to aggravations of their diseases at 
times. 

I find that the younger the patient the greater is the tendency to 
periodic alternation, remission, and relapse. The phenomenon finds its 
acme in the cases of pubescent and adolescent insanity. 

I also find that the stronger the heredity the greater the tendency to 
periodic relapses and alternations. I have never met with a single case 
that could be called tjpicul foUe circidaire where there was not hereditary 
predisposition to insanity. It seems as if there were certain brains so 
constituted as to be incapable of energizing except irregularly, swinging 
between elevation and depression, like a kad electric light. The above 
facts and statistics refer to ordinary remissions ; but the infrequency of 
cases with such regular and continuous alternations as to be properly 
called folie circidaire may be seen from tlie fact that out of eight 
hundred patients in the Asylum at Morningsidc now tliere are only six- 



184 STATES OF MENTAL ALTERNATION. 

teen of this kind, or two per cent., and of the last three thousand new 
admissions, comprising about two thousand fresh cases of insanity, less 
than ten have as yet turned out of this character. But, of course, I do 
not include the cases with merely long remissions, or the cases with 
relapses for the first year or two, or the demented cases with occasional 
spurts of excitement, or the women with a few irritable days at menstru- 
ation, though many of these are of the same essential nature as the most 
typical cases of folie circulairey following the same law^s of physiological 
periodicity in an irregular way. 

I have had under my care altogether about forty cases of typical foUe 
circulaire. Of these about one-half followed a more or less regular 
monthly periodicity. About one-third obeyed the law of seasonal period- 
icity, all in an irregular way ; and the remaining sixth I could bring 
under no known law on account of their irregularity. I have one extra- 
ordinary case now, a lady, who was for a year deeply depressed, then for 
several years quite well, then for seven years more deeply depressed, then 
for three months passed for sane, but was really mildly exalted, then was 
depressed for a year, and has now been exalted, with all the typical 
symptoms of typical /oZz'e circulaire, for two years. 

Commencement of the Alternating Tendency. — Though there 
are a few cases that begin with attacks of melancholia, yet in my experi- 
ence at least ninety per cent, begin with attacks of maniacal exaltation. 
The ages of the patients on the first breaking out of the disease were all 
the way from fifteen to seventy-four; but every one, except the one D. C. 
(p. 177), began within the actively sexual and procreative period of life. 
I find no record of a woman's case beginning after the climacteric period. 

Termination of Typical Folie Circulaire. — As this cannot be 
determined till after the patients have died, it is impossible for me to give 
accurate figures; but, of forty cases, five ceased to be subject to alterna- 
tion in old age after sixty, one of these was above eighty, two being 
women. The men were all left in a condition of mind and brain that 
might be legally reckoned sanity, though in all cases there was some 
mental enfeeblement or a tendency to be easily upset, w4th lethargy, want 
of spontaneity, and of volitional power. One case terminated in complete 
dementia. Two ran on into chronic mania. Two died of exhaustion 
during a maniacal period. Three things are sure about the prognosis — 
1. Its utter uncertainty. 2. Recovery cannot be looked for at the 
climacteric period in many cases. 3. About twenty per cent, may be 
expected to settle down into a sort of quiet, comfortable, slightly enfee- 
bled condition in the senile period of life. 4. In my experience very 
few, indeed, become completely demented. 5. The tendency to death is 
very slight. 

General Conclusions. — Looking at all those facts and considerations, 
therefore, I come to these conclusions. That periodicity or a tendency 
to alternations of elevation and depression is an almost universal charac- 
teristic of mental diseases; that it is much more marked where they are 
very hereditary than in any other cases; that it is more common in 
youth, puberty, and adolescence than at other periods ; that it is in its 
essential nature merely the exaggerated or perverted physiological 
diurnal, menstrual, sexual, or seasonal periodicities of the healthy brain ; 



STATES OF MENTAL ALTERNATION. 185 

that the cases that have been called folic circulaire, katatonia, etc., are 
merely typical or exaggerated or more continuous examples of that 
universal tendency to which I have referred. Another remarkable fact 
about the typical form of alternating insanity is, that by far the greater 
number of persons who suffered from it were persons of education, and 
far more than a due proportion of them were persons of old families. I 
never met with a fine case in a person whose owii brain and whose 
ancestors' brains had been uneducated. It seems to me that the 
tendency to alternation of mental condition, to energize at one time with 
morbid hurry and then with morbid slackness, is one of the forms of brain 
instability which specially results from too much "pureness of blood," or 
from the heredity of many generations of gentlefolks, all of whose brains 
had been more or less educated. Probably it is one of the modes by 
which nature brings that kind of stock to an end that has become bad by 
over-brain cultivation for many generations. 

Real work can sometimes be done during the sane periods. D. D. has 
done some literary work, in the intervals of his attacks, for the twenty- 
six years he has been ill. 

I have no doubt that it was the sexual and menstrual periodicity of 
mental diseases, seen in so many cases, that formerly originated the 
absurd idea that they depended on the moon's changes, and gave them the 
name of "lunacy." 

Treatment. — The great point in treatment is to prevent the brain 
getting into the vicious circle of continuous alternation by endeavoring 
really to complete the cure in all cases of mania — especially in all cases of 
adolescent mania — and by prolonged quiet and brain-rest after attacks in 
persons who have shown a tendency towards recurrence and relapse. In 
them particularly the whole organism should be kept up to physiological 
perfection. I believe that a non-stimulating farinaceous vegetable diet 
and no alcohol is the best for them, with an outdoor life and plenty of 
muscular exercise. A regular mode of life, too, without excitement, is 
best. One thing which I have heard recommended, and Avhich is very 
liable to be resorted to in the beginning of the exalted stage when the 
patient is very erotic, is marriage, but I have never seen any good come 
of it either by cure or prophylaxis. I once, with Dr. Heron Watson, had 
to stop the banns in the case of a lady who had been seduced in the begin- 
ning of the exalted erotic stage of this disease, and was going to be 
married for her money by a scoundrel who had taken advantage of her 
mental condition. I mentioned in the case of D. A. that he usually pro- 
posed to many ladies at the beginning of his exalted attacks. There is 
only one class of medicines that I know which have any power of stop- 
ping or cutting short attacks, and of sometimes averting them for a long 
time, and these are the bromides, especially combined at the more acute 
stages with Indian hemp. The following three cases illustrate this action : 

D. F., set. 23. This young woman has had six attacks of mania in 
four years. She had been insane for four weeks previous to admission. 
All the attacks had begun during menstruation, and while maniacal she 
was always very erotic, especially at \\\q beginning of the excitement. 
She was violent, incoherent, noisy, dirty in her habits, and sleepless 
before admission and for about three months afterwards. She then izot 



186 STATES OF MENTAL ALTERNATION. 

well, but in six months had another similar attack of mania, lasting for 
two months. She lost twenty-eight pounds in weight during this attack, 
and her temperature Avas always 1.5° above its normal rate during the 
excitement. She remained free from excitement for nine months, and 
then had another similar attack. After four months of sanity she one 
night suddenly got up, smashed the windows of her dormitory, saying 
that the devil was looking in, and became violently excited, her tempera- 
ture that day being 100.8°, pulse 108 and strong. She was ordered 
drachm doses of the bromide of potassium every three hours, with a 
drachm of ammoniated tincture of valerian with each dose. She was 
put into a dark room at her own suggestion. On the following day her 
temperature was 99.6°, and her pulse 108. She was still much excited, 
but not so much as on the day before. On the second day her tempera- 
ture was 99.3°, and her pulse 130 and weak, the excitement being much 
allayed. The medicine was after this given only three times a day. 
She was left in bed for a fortnight in a dark room, as she said that if she 
got up she would get worse. At the end of that time she was still 
rambling, partially incoherent, and full of delusions, but nearly free from 
active excitement, and the medicine was discontinued. She remained 
slightly affected in mind for another fortnight. At the end of a month 
from the day the excitement began she was well, and was discharged 
from the asylum six months thereafter. I heard that she was still keep- 
ing well a year from the time of her attack of mania, which was thus cut 
short (as it seems to me) by bromide of potassium. I gave the valerian 
because she was beginning to menstruate at the time the mania began. 

It will be observed that the excitement in this attack only lasted about 
three days, and she had never been less than two months excited at a 
time in her nine previous attacks. The aberration of mind was only of 
a month's duration. It had never been shorter than between three and 
four months previously, every symptom of an ordinary attack being 
clearly present at first ; and the interval of sanity has been even now 
longer than any such interval except that between the fifth and sixth at- 
tacks. The excitement disappeared as the patient showed signs of coming 
under the influence of the bromide, and its constitutional symptoms were 
developed. 

D. G., set. 56, a woman who has been rather weak-minded from birth, 
but got married and had children. She has been subject to attacks of 
excitement at intervals of a year or two for twenty years. On her ad- 
mission from another asylum she was found to be a little, thin woman, 
who went on talking quite incoherently, was restless and destructive to 
her dress, and violent at times. Sometimes she refused her food, and 
had to be fed with the stomach-pump. Though she got much food and 
stimulants, she became quite run down, thin, and exhausted in mind and 
body before the attack was over. The first attack lasted from March till 
the following January ; she had a short attack in April. In the begin- 
ning of the next year she had another short attack, and in the December 
following she had three epileptic fits (the first she ever had). They were 
the prelude to an attack of excitement which lasted for six months. In 
the following year she had another attack of excitement lasting for three 
months. In the beginning of this year she again became excited, and 



PLATE IV. 




STATES OF MENTAL ALTERNATION. 187 

was put on drachm doses of bromide and tincture of Indian hemp, three 
times a day at first, and afterwards morning and evening. The medicine 
so completely moderated all the unpleasant symptoms of the excitement 
that she was kept in the infirmary ward among the sick patients. She 
was not noisy, destructive, or dirty in her habits, as she had been before; 
she did not lose flesh to nearly the same extent as before ; she took her 
food better than ever she had done before during excitement ; and the 
attack terminated in September, leaving her far stronger than she had 
ever been after so long an attack of excitement. 

This case illustrates the effect of the medicine on an old person very 
weak in body, and perhaps, therefore, more amenable to the effects of the 
drug. Such cases, when violently excited, are far worse to manage and 
cause far more anxiety than stronger patients in asylums, and therefore 
it is more important to have' a mild and safe sedative. 

Another case is that of an old woman who has taken periodic attacks 
of mania for at least twenty years, and has been so much better during 
her last attack, under the use of drachm doses of the bromide and tinc- 
ture of cannabis morning and evening, that she has been kept in the in- 
firmary ward of the asylum during the nine months the attack has lasted, 
and has, during that time, slept in a dormitory with other patients, has 
taken her food, and is now passing into the quiet stage of her disorder. 

Pathology. — As regards the pathological appearances found after 
death in cases of prolonged alternating insanity, I found in all of them 
more or less brain atrophy, especially affecting the convolutions, in all 
of them thickening of the membranes, in most of them thickening of the 
skull cap. One case, who had been twenty-five years ill, showed an 
amount of deposit of bone on the inner table of the skull I have never 
seen before (see Plate IV.). In most of them there was vascular disease, 
with, in one or two cases, local disintegration from embolisms and other 
results of blood-starvation. In short, I found the common pathological 
appearances in cases of chronic insanity, but with no special pathology 
whatever. That is what might be expected, for at the beginning the 
mental functions are so nearly restored between the attacks that we can 
expect no marked pathological changes. The whole tendency to periodi- 
city results, no doubt, from a mode of energizing, and not from struc- 
tural change that can be seen after death. No doubt such a deposit as 
that figured in Plate IV. is secondary and partly compensatory for the 
brain atrophy, but, like many of the changes of structure in the bones 
and membranes of the brain in chronic insanity, it is very instructive in 
the light it sheds on the pathogenesis of the disease. If the intensity of 
the morbid action was so great as to cause such structural changes even 
in the bones, how great must it have been in the convolutions, its primary- 
seat ! 



LECTURE VI. 

STATES OF FIXED AND LIMITED DELUSION (MONOMANIA, MONO- 
PSYCHOSIS, DELUSIONAL INSANITY). 

The study of this form of mental aberration should, like that of every 
other form, he begun from a physiological point of view. There are all 
sorts of false sense impressions and false intellectual beliefs which are 
due to mere physiological laws. When a light is rapidly intermittent 
and appears to the eye to be continuous, when the sensation of the toes 
and their movements are felt in an amputated stump, and when one is 
deceived by the quick movements of a juggler, we have for the time 
sense delusions. When through brain fatigue, brain poisoning, or dis- 
turbance of the circulation, objects are seen double ; or when the old im- 
pressions on the perceptive centres of the brain are projected and appear 
to be seen as real objects, the true nature of which have to be ascertained 
by the judging faculty, we have real hallucinations, but not insane hal- 
lucinations. The whole mental life of a child in its very early years, 
before its senses are trained or its judging power developed, is one series 
of delusions. The superstitions of the ignorant are delusions, but they 
result from lack of training and want of development of the judging 
power, not from a diseased perversion of it. When lately a great part 
of the Mohammedan population of Constantinople turned out one night, 
and with frantic gesticulations, great shouting, and firing of guns, tried 
to frighten away a beast which they believed to be devouring the moon 
when it was eclipsed, they labored under a delusion of ignorance. I 
have heard a perfectly sane but ignorant woman in Cumberland say that 
every time she had sat by the bedside of a dying person, she had heard 
the " Death Clock" in the wall; and whenever she heard that, she knew 
the patient was going to die, and had never been deceived. You meet 
with people who believe that certain things are going to happen on 
utterly absurd grounds, and so labor under delusions in a popular sense. 
Dreaming and nightmare give you the best idea of an insane delusion, 
and are the nearest physiological counterparts of it. A sufficient amount 
of fatigue and exhaustion from want of sleep will produce a condition in 
almost any brain that is closely allied to that of the monomanaic. 

Such "delusions" have little relationship practically to "insane de- 
lusions," however much they may resemble them in certain respects, or 
however much they may be psychologically allied to them. The delu- 
sions that are really half-way house between those I have referred to 
and the true insane delusions are the false beliefs of imbeciles and the 
temporary delusions of persons whose emotions have been strongly 
roused by religious services or contemplation, as when they see visions 
or hear voices. The imbecile has deficient judging power from want of 



STATES OF FIXED AND LIMITED DELUSION. 189 

brain development, and often has, in addition, morbid energizing of his 
convolutions. His delusions have often to be treated as insane delu- 
sions, as when he imagines he is married to a woman, and wants to act 
on his belief, or when he thinks his neighbor's property is his own, and 
proceeds to use it. To us, as. practitioners of medicine, the " insane 
delusion" is the one that affects the conduct or life, provided it results 
from a morbid condition of brain, either through deficiency or disease. 
An educated man who behaved in Princes Street as the Turks behaved 
during the eclipse would certainly be regarded as laboring under an 
insane delusion, and would run much risk of being sent to an asylum. 
The education, age, class, and even race in some degree determine 
whether any given false belief is an insane delusion or not. This is not 
perhaps scientific psychology, but it is the practical way we have to look 
at the matter as physicians. The whole subject of false sense percep- 
tions, sane hallucinations, and unreasoning unfounded "instincts" about 
things, though most interesting both from the physiological and medico- 
psychological side, I must not dwell on here too long. 

An "insane delusion" may therefore be defined to be "a belief in 
something that would be incredible to sane people of the same class, 
education, or race as the person who expresses it, this resulting from 
diseased Avorking of the brain convolutions." There was once an old 
gentleman, D. L., a patient in Morningside Asylum, who in his man- 
ners and conduct was all that was gentlemanly ; in his emotional nature 
was benevolent to a high degree; and in his dress and deportment ex- 
hibited no peculiarity whatever, but who calmly asserted that he was 
many thousand years old ; that he had known Noah rather intimately, 
and found him a most sociable man, but "a little too fond of his toddy;" 
that he once w^ent out snipe-shooting with King David, who was a crack 
shot ; and one day gave St. Paul a lift on his gig on the Peebles road. 
I once had a patient, D. M., at the Carlisle Asylum, who was acute 
intellectually and morally irreproachable, but who, ever after a hemi- 
plegic attack, believed that twice two were not four, but four and a 
quarter, and who spent his whole time not devoted to keeping the asylum 
accounts — which he did accurately on the "old system" in deference to 
our prejudices — to making elaborate calculations by his own mode of 
arithmetic as to the distances of the stars and a new system of loga- 
rithms, constructing new quadrants, etc. The manuscripts filled two 
large chests at his death, which he solemnly left by will to the Univer- 
sity of Oxford. In both these cases there was no trace of the morbid 
mental depression or the exaltation that I have described. The delu- 
sions, which were perfectly fixed and unchanging from year to year 
during the lifetime of the patients, really constituted the insanity, and 
were examples, therefore, of delusional insanity or monomania. There 
are very few, if any, examples of a pure monomania — that is, of a 
person who has one single delusion, and that alone. The ordinary form 
of this type of mental disturbance is for the delusions of the patient to 
refer to one particular subject or set of subjects, or for him to be morbid 
in a particular direction of intellect or feeling, while ho is sound in 
most directions. The chief directions such delusions take arc — a. of 



190 STATES OF FIXED AND LIMITED DELUSION. 

unreal greatness, h. unfounded suspicions, and c. unseen and impossible 
agencies. 

Monomania of Grandeur or Pride. — I have a pauper patient, 
D. N„ who believes himself to be the rightful king of England. He 
looks sane, and is perfectly quiet and self-possessed in manner. He is a 
well-developed man, far above the average of his class in general looks 
and in facial expression. He told us his story with perfect calmness 
and coherence, rather apologetically, and saying he knew we would 
probably not believe him if he said he was heir to the throne. Then 
when he came to tell about his betrothal at thirteen to Queen Victoria 
(I have had a score of patients who were to have been married to her 
Majesty), and Prince Albert's adroitly slipping in, he got on to ground 
purely imaginary and delusional. The whole story was a queer mixture 
of wholly imaginary premises and much sound, but also much unsound, 
conclusions from them. Insane people generally do not reason rightly 
from wrong premises, as Loche said, but some of them do; and the 
simply delusional and the melancholic cases are usually the classes who 
approach nearest to this description. It is most difficult, if you believe 
his case is incurable, to pick a flaw in the reasoning of a melancholic 
who says, "I am miserable and incurabl}^ ill, and shall get worse, and 
lose what reason I have got. I believe all such people are better out of 
the way. I have all my life believed this ; therefore, I mean to put an 
end to myself as soon as possible." One premise is correct, and the 
other was held by him to be so when he was quite sane, and is held by 
many sane people. But in the case of the monomanaic, one of his pre- 
mises is indubitably wrong in the estimation of all sane people, but you 
cannot convince him of this. If twice two and two had made four and 
a quarter, as D. M. said it did, then it was not absurd to have devoted 
every spare moment of his life to the demonstration that the world had 
fallen into a serious error, and to working out a new system of astronomy 
and logarithms on a correct basis. D. N., the king, is an excellent 
blacksmith, and we get him to work at his trade in our shop. Nowa- 
days we do not allow our monomaniacs or insane people generally to 
dress themselves or to look like what they believe themselves to be, as 
they did of old. The antipathy to individualism which affects society 
in every direction is strong in asylums for the insane. We now dis- 
courage those outward manifestations of insane delusions that used to 
give a lunatic asylum its most striking character. The monarchs crowned 
with straw, the duchesses in gaudy spangles, the field-marshals with gro- 
tesque military uniforms, that could be seen in any asylum of old, you 
will not now see when you go through our wards. If the man with the 
millions of money, who is the rightful heir to the throne, affixes the top of 
a soda-water bottle to the front of his cap as a faint symbol of his position, 
it is at once unfastened. If the princess, who is the greatest beauty in 
Europe, bedecks herself too conspicuously with bits of colored glass and 
in conspicuous ribbons, they are quietly removed at night. The insane 
man, like his sane brother, in most cases soon adapts himself to his circum- 
stances, and submits to rule and public opinion. The last of the great 
characters of the older period of this asylum, D. 0., lived on into the 
present regime, and was allowed to wear the insignia of his rank, but I 



STATES OF FIXED AND LIMITED DELUSION. 191 

have allowed no successor to arise. He was the " King of Kings," and 
wore a most elaborate croAvn of many colors, each part of which had a 
symbolic meaning. He was so picturesque a character about the place, 
and was so striking a clinical illustration of monomania of grandeur, and 
withal so harmless and useful in the garden, that I never ordered him to 
be discrowned. He had certain visions from heaven which he reduced 
to concrete forms in drawings and polished stones, and his relations with 
Queen Victoria were most intimate. One "cloud of the Lord" which 
he once saw on the top of St. John's Church, had taken most vivid hold 
on his imagination, for he cut likenesses of it on the bark of almost every 
tree in the asylum grounds, where they will remain for perhaps hundreds 
of years. The tendency to symbolism and morbid outward decoration is 
much stronger in the Celtic races than in the Teutonic, and in the female 
than in the male sex. In the Highland asylums it is almost impossible 
to make the patients abandon their conceits in dress. Such changes have 
their drawbacks, for no Dean Ramsay of the future will be able to compile 
for us such delightful stories of our fools, and our writers and artists will 
have to look out for less striking environments for their madmen than 
fool's caps and gewgaws, or chains and filth. 

Hallucinations of the senses are very common in this whole class, and 
also delusions as to the identit}^ of the persons around them. I have a 
gentleman patient who, whenever he goes into Edinburgh, meets the late 
Emperor of the French, or the late Prince Consort. So marked is this 
tendency in some cases that it might be called a special form of mono- 
mania, that namely of mistaken identity. It is well illustrated in this 
letter of D. 0. A. : 

"My dear Mamma, — I have been long in answering your last kind letter, but 
the real reason is that I have been always so scarce of news to give you that I could 
never make up my mind to sit down and write ; indeed, I cannot say that I have 
anything to say at present. I was out on Saturday seeing Signor Bosco's magical 
entertainment in the Masonic Hall. I think I will just tell you all my ideas about 
the people here, as I do not think that they are fancies of my own. Old Captain G., 
surgeon of Uncle T.'s dragoon regiment, is here; he calls himself Dr. S., but I don't 
mind that. 

" Sir J. H. is here too, calling himself J. S. ' With frisking airs Miss pussy tries 
the power of she's gooseberry eyes to win the heart of every swain.' He is attendant 
on a Mr. Y., whom I have no reason to doubt now is a brother of the operatic singer 
that the Duke of Cambridge shot in the theatre in Vienna. I am positive that I saw 
Sir A. in the Meadows without his case of false teeth. Emperor Yea of China is here 
too, calls himself Mr. B. ; he is kept bj^ a son of Lord C. Peter D. is head gardener 
here ; he, his wife and family live at the lodge at the gate on the road out to Comiston. 
S. D. is here on the ground flat ; 1 think, when I recollect right, you put that idea 
into my head out at P. He is attended by Malcolm, a son of Abraham Lincoln's. 
He writes squibs in the papers about the ' Solo ' royal family. He gets the papers 
printed over at the asylum press for my use, but I never read them" Maggie F.'s 
brother is also one of the attendants here. Bell, the brother of the Private Bell of the 
6,th D. G., is here acting as general scogey. He is the man that J. bought AVasp 
from. The matron of the East House here is a sister of my attendant's-^ they arc 
both children of Lord C, and their mother is the cook to the East House. Abraham 
Lincoln's wife is here, kept by Miss D. Wilkes Booth and Miss Eeynolds, Gregory, 
Mag Walhice and old Armstrong son is head attendant of the I'nale wing, East 
House. 

" Kind love to you all, and I remain, my dear edie, 

" Your most aflec. son, " D. A. O." 

"Am 1 in a trance again when I say that you really cooked and eat the meat which 
came off my head ?" 



192 STATES OF FIXED AXD LIMITED DELUSION. 

But to return to D. N., who may be taken as a typical case of mono- 
mania of grandeur, his mind is not only affected by the delusion that he 
is king, but it is affected by an unreal tendency to elevation in all direc- 
tions, and it is also now somewhat enfeebled, as is commonly the case 
after manv years in such cases. He often writes me long; ramblinor 
letters, proposing various impractical modes of managing the asylum, and 
he is the greatest fault-finder in it. Then affectively he is different from 
a sane man, showing small love for his wife or children, and he takes 
morbid dislikes to people without real cause. He once went down to 
Leith to see his family, and went to all the houses of a certain street 
which he imagined belonged to him, and gave the inhabitants due notice 
to quit at the next term. He is, of course, very inconsistent to work as 
a blacksmith, he being a king ; but the conduct of by far the majority of 
the insane is quite inconsistent with their beliefs ; and then if he did not 
work, he would get no tobacco or beer to lunch, arguments that even 
royalty can appreciate. Sometimes the kings and cases of monomania 
of grandeur will not occupy themselves in common occupations. I have 
a "prophet of the Lord," D. 0. B., a joiner, who by no means at our 
disposal can be got to work at his trade. He says that the Lord has 
sent him a new work, and he must follow it. He sees visions from God 
all the time, which he puts down on paper, green and blue angels, sapphire 
prophets, etc. He will go to no amusements, or to church. I have 
another man, D. 0. C, with almost precisely the same delusion — viz., 
that he is a " man of God " — who is a capital worker in the garden, and 
enjoys a dance or a concert immensely. The mental disease in D. N. 
was first seen thirty-four years ago in an attack of melancholia from 
which he recovered in four weeks, and the present attack began twenty- 
nine years ago, also with an attack of melancholia, which, as it passed 
away, left him in his present condition. There is a strong heredity to 
insanity in his family, his brother having been a melancholic and com- 
mitted suicide, and his eldest daughter, D. 0. D., has been a patient here 
since she was twenty-two, being now a case also of monomania of grandeur, 
and believing herself to be a princess ; and her insanity began with melan- 
cholia. She is like her father, but was begotten when he was sane, when 
therefore his disease was with him a mere potentiality. But this is often 
seen. That law of neurotic heredity through which in each successive 
generation the neurosis appears at an earlier age than in the preceding 
one was exemplified in this case, for the father was thirty-three when he 
first became insane, the brother, who committed suicide, thirty-two, while 
the daughter was only twenty -two. The tendency towards early dementia 
that is usually seen in such strongly hereditary cases if they do not re- 
cover, is shown here, for along with her delusional condition she is also 
much more mentally enfeebled than her father, not being able to employ 
herself, not taking interest in anything, and having no mental vigor or 
spontaneity. 

In addition to the cases I have mentioned, I am able to present to you 
some of the most remarkable personages that have ever lived. Here is 
Jesus Christ, and here are the Prophet Elias, the Emperor of the Uni- 
verse, the Universal Empress, Empress of Turkey, the only daughter of 
God Almighty, Queen Elizabeth, four kings of England, one king of 



STATES OF FIXED AND LIMITED DELUSION. 193 

Scotland, the Duke of Kilmarnock, the inventor of perpetual motion, a 
man who has discovered the '' new elixir of life " that can cure delusions, 
twelve persons to whom this establishment and all that it contains belongs, 
a ladj who daily and nightly has delightful conversations with the Prince 
of Wales and the rest of the royal family, a man who is to renovate 
humanity, and cure all our existing ills by means of a scheme he has in 
his head. The gentleman who has discovered the "hew elixir of life" 
wrote out an advertisement setting forth its infallible virtues that would 
have done credit to the most successful patent medicine proprietor. He 
used to make it up in the asylum, and wanted much to try it on the 
patients, but none of them believed in him or would take his nostrum. 
But he w^as allowed to go out for a walk into town occasionally, being a 
harmless man, and I found that he used to take a few of his bottles with 
him, and sometimes sold them at five shillings apiece — this monomaniac 
— to sane citizens of Edinburgh ! 

Those are all calm and harmless people, some of them bearing them- 
selves in their deportment and manner as become such distinguished 
personages, though a few do not exhibit any outward or muscular indica- 
tions of their greatness, all in some way inconsistent, and absolutely un- 
moved by the most conclusive argument or evidence that their ideas are 
wrong and unfounded. They all looked on me as the fool to be pitied or 
contemned, who could not see their greatness. They were all in good 
bodily health, and all looked as if they would live as long as any of us. 

In considering the origin of this form of mental aberration, we see that 
all this imaginary grandeur and power has a physiological foundation in 
the brain-working of every man. The wildest of these beliefs are not 
half as extravagant as the day-dreams, imaginations, fancies, castles built 
in air, and longings of nearly every man and woman. And in comparison 
to the imaginings or even the beliefs of a child, they are tame. Compared 
with the dreams of most men, they are very reasonable indeed. It is very 
easy to conceive how the brain of a man with a heredity to insanity, of 
unstable constitution, of a proud imaginative disposition, would, when it 
became disordered in working from any cause, readily play its owner the 
trick of making him believe his day-dreams and longings to be realities. 
Once impair the judging power that enables us to compare and estimate 
facts, and we should all be kings or very great men at once. 

Sometimes the monomania of grandeur is combined w4th that of sus- 
picion and persecution. 

Monomania of Unseen Agency. — Another marked type of delu- 
sional insanity is that of unseen agency. Such patients believe that 
they are electrified, that they are mesmerized, that noxious gases are 
blown into their bedrooms, that people speak to them and call them bad 
names through walls by telephones and out of the ground, that spirits 
and devils haunt them, that persons come to them at night and break 
their bones or ravish them, that persons read their thoughts, or have 
power over them to act on their thoughts. Most of those delusions im- 
ply a sense of ill-being on the part of their subjects, or pain or discom- 
fort, the origin of which the patients misinterpret. I had a woman who 
for long believed the devil was inside her. At the point whore she said 
he was, I discovered a cancerous tumor, of which she died in a few 

13 



194 STATES OF FIXED AND LIMITED DELUSION. 

months. This was merely assigning an insane and impossible cause for 
a real pain which she felt. Such cases are common. One of the most 
typical examples of delusions of being affected by electricity — and this 
and mesmerism are the two most common of all unseen agencies of which 
the insane complain — was that of a woman, D. 0. E., who, at sixty-four, 
became possessed with the delusion that people were electrifying her at 
night. This idea came on gradually, with a little depression at first, 
until it made her life an evident burden to her, unfitted her for all work, 
and she accused her neighbors of " working the electricity " on her when 
she was sent to the asylum. We found she had had heart disease, ac- 
companied evidently by angina. The pain of this she attributed to people 
electrifying her. This continued, and got worse, till her death from the 
heart disease. In her dying moments she accused us of causing all her 
pain by the electricity, and aflSrmed that this was killing her. I have a 
case now with "a big serpent inside," in which the delusion originates in 
angina. It is more common to have delusions, and not to be able to 
trace out such obvious causes as those two cases. All constitutional affec- 
tions, such as cancer, tuberculosis, rheumatism, alcoholism, and especially 
syphilis, which cause brain anaemia, and local disturbances and pains, 
may, in a person whose brain is predisposed to mental disturbance, cause 
delusions of unseen agency. Dr. Hugh Gr. Stewart long ago described 
certain syphilitic cases who imagined that noxious gases were blown into 
their rooms at night, or driven into their nostrils. To prevent this they 
stopped the keyholes of their doors at night, plugged their nostrils and 
ears, wrapped their heads up. I have met with many such patients. It 
is evident that there is a general sense of organic discomfort in such men, 
which is misinterpreted into those delusions. Frequently the chronic 
irritation of the drunkard's stomach is attributed by him to living ani- 
mals inside, or to poison. I once had a patient, D. P., who had been a 
great drunkard, and had had many attacks of acute alcoholism, who said 
he had mice inside him, gnawing and running about. He was gradually 
cured or recovered in about two years, under a teetotal regimen, bismuth, 
easily digested food, and fresh air. I give here the letter of a syphilitic 
case, D. Q. : 

" Forced dreaming, forced vomiting from the stomach, forced glut vomiting from 
the throat, cold shivering by the forced thinking, sweating done in the same way, 
pains in the stomach any way the}^ think. I think it is time ihat this way of pun- 
ishing should be stopped, and let me know if there is anything going to be done for 
my benefit; and I want to see about bad usage. I think it was lime it was stopped. 
I would thank you to let me know the real truth. — I am, &c." 

This man was an old soldier, and had on admission all the appearance 
of the syphilitic cachexia. He used to talk constantly about his delu- 
sions, and be rather dangerous, but now, after five years, he never men- 
tions them except he is spoken to about them, and in fact scarcely speaks 
.at all. His bodily health is much improved, and he works in the garden 
every day. The following letter was written to me by a man, D. R., 
who was very dangerous indeed from his delusions, often threatening to 
kill me, and, he afterwards said, often seriously deliberating whether he 
would do so or not : 



STATES OF FIXED AND LIMITED DELUSION. 195 

"Ist April, 1868. 

" Mr. Clouston, — I now take the opportunity of writing you these few lines to 

let you know that I am quite well in health, but you have punished me sore, and I 

do not know what it is for. A week or two after I came here you let me alone, and 

then you started and did wrong with me, and all your attendants had some stuff' to 

stifle '^me with. I think it is a disgraceful aftair, and John very nearly choked 

me. Some, too, at the table, for I think you have them put pn to do so, and in the 

bedroom there is Adam , for I have catched him, and told him about it. On the 

18th of February you crushed my breast, and on the 20th you crushed my left side in. 
I thought you had done for me, and on the 21st b^ebruary you crushed the right side 
in. And the curious conversations you have been making with me at nights. It's a 
shame atid a disgrace. You ought not to try to kill me altogether. I have stood 
bad treatment that would have killed ten men, and you ought to put a stop to it, for 
I have done no wrong, &c." 

This man seemed in perfect bodily health, and I could not discover 
any peripheral causes for the painful sensations he probably had, and 
which he so misinterpreted. But in every case I advise you to examine 
carefully into the condition and working of the great organs and func- 
tions, and the history of the patient, to find out whether there has been 
syphilis or rheumatism, or other constitutional disorder. Such delusions 
of unseen agency are often associated with hallucinations of hearing. 
Patients fancy that people whisper through floors, and down chimneys. 
One patient I had was tormented by people speaking down the chimney, 
another was constantly annoyed by people talking to him through tele- 
phones, and a man who had been a heavy drinker, and had acute alco- 
holism several times, said he was constantly subjected to a process which 
he called "ric-me-tic." That persons read their thoughts and influence 
their thoughts are very current delusions. , Patients almost always com- 
plain most of unseen agencies at night, just as they have hallucinations 
most at nights, when there are no conflicting real impressions on the 
senses. It is very common for women to have the delusion that they are 
made insensible, and ravished at nights. One can, of course, more 
readily understand the explanation of such delusions than of others. 

I am told it is very common, indeed, for criminals undergoing solitary 
confinement in penal servitude to have delusions that they are worked on 
by electric batteries. Their weak degenerate brains, natural suspicions, 
ignorance, and the occasional use of the electric battery to detect impos- 
ture among them, seem to account for this. I once had such a man sent 
from Broadmoor Criminal Asylum to the Carlisle Asylum at the expira- 
tion of his sentence, a strong bad-looking, dangerous fellow, whom we 
regarded as the worst man in the place. After a few months he escaped, 
and after being in hiding among his friends for a short time, began to 
work, and has remained an industrious, self-supporting member of society 
ever since, and that after having been for ^^ears regarded as a most dan- 
gerous criminal luiuitic. No doubt, having first to secure his safety from 
recapture and then to earn his own living, and being away from those 
whom he would consider his natural enemies, his mind would be dis- 
tracted from his delusion, and it would cease to have its former power 
over him to influence his conduct. 

In some few cases delusions of unseen agency are pleasant to the pa- 
tient, or at all events are not complained of. Some of the sexual cases 
are of this character. Such was the case in the man D. S., who wrote 



196 STATES OF FIXED AND LIMITED DELUSION. 

me this letter : ^^ Record of Miracles, — The Reverend came 

to see me, and his countenance changed to that of my deceased uncle 

. My length while in bed was increased to about seven feet, 

and then made normal. When in bed a very pretty colored landscape, 
including cottage and woman at her washing-tub, appeared on the wall. 
The picture could not have been produced by the aid of the camera. 
P. Smith, casting a wry look at me, jumped from the floor to a height of 
a foot, then passed through a framed picture without injury thereto, and 
through a solid fourteen-inch stone wall, then came through the water- 
closet door to meet me. While peering in at the laundry windows a 
number of the girls' clothes flew off them while at their washing-tubs, and 
after about half a minute's nakedness their clothes came back to them, 
and they were properly fastened without their aid. Near Myreside Cot- 
tage, James S., astride a thin wire fence, was seen speeding along for 
about one hundred yards, the wooden posts forming no impediment to 
his 'wiremanship,' &c." 

I have under my care at present a gentleman, D. T., who believes he 
is under the power of " an automaton," which controls him, makes him 
scream out, talk nonsense, break dishes, etc. He is a quiet and most 
courteous gentleman, who, after having done one of those things, will 
reply, if asked w^hy he behaved so, in a peculiarly measured calm manner 
— " The automaton made me do it. I did not wish to do anything of the 
sort." He will say sometimes, still more calmly, " Will you write to the 
commissioners to remove the automaton ?" "I beg to renew my request 
of the 14th of July." 

Monomania of Suspicion. — The third great class of delusional cases 
are those of suspicion and persecution. This kind of delusional condition 
is essentially the same as the last, only it is not so great a departure from 
soundness of mind, but for convenience sake we separate them. Patients 
who labor under this form of mental disease do not attribute their annoy- 
ances to unnatural, unseen, or impossible means, but to the malevolence 
of real persons who plot against them, have evil designs on them, poison 
their food, annoy them, persecute them, prove unfaithful to their marriage 
vows, etc. We all know that the natural development of suspicion is very 
various in different people. Many people are of a suspicious temperament 
from the beginning, others are made suspicious by real experiences in life 
or by ill health. We know that the weak are always suspicious through- 
out the whole of the animal kingdom. It is the same with human brains. 
An element of morbid suspicion exists at the beginning of nearly all 
cases of melancholia. Nothing is more common than for such persons to 
imagine that people are looking at them, watching them, and following 
them about. I look on this as mental evidence of an ill-nourished or 
anaemic brain. But in the class of persons of whom I am to speak it is 
a chronic manifestation of a disordered brain. As we shall see when I 
come to talk of phthisical insanity, morbid suspicion is the most constant 
sign of the brain malnutrition that goes with a combination of a heredity 
to tuberculosis and to insanity. A man, D. T. A., who is a patient of 
mine, is full of suspicions about everyone near him. He thinks that 
everyone about annoys him on purpose. If another patient coughs, it is 
to annoy him ; if one spits, it is to insult him ; if one sings, the words 



STATES OF FIXED AND LIMITED DELUSION. 197 

refer to him. His career is instructive. He was a soldier, and lived 
hard, had an attack of acute mania, and when the exaltation and excite- 
ment passed off, he was left in his present condition, and has remained 
so for twenty-one years. For the first thirteen years he was regarded as 
a dangerous man, and it was feared to put any sort of tool or instrument 
into his hand, for he was the hero of many fights — in fact, fought or 
wanted to fight some one every day. But as he was a tinsmith originally, 
and I found him one day in a better humor than usual, I sent him to the 
tinsmith shop of the asylum, not without fears that he might murder 
some one. He had just before written this letter: "I write to you to 
let you know that I am much abused here by villains. I will be clear 
of the band of villains they have upon me. Be so good as come before 
they kill me. I am not able to stand death here. They have poisoned 
me many a time. I will not stand the bloody abuse that they are giving 
me. A fellow they call Hamilton [a fellow-patient who talked to himself] 
is abusing me most awfully," etc. With much tobacco and a little beer, 
of which he was very found, and many promises that all the " villany " 
would be ended if he would work well and not fight, we set him to work. 
He took to it at once, worked as if his life depended on it, hammered 
away at tin and copper plates, making them into utensils, and evidently 
found much satisfaction in the outlet that unlimited hammering and much 
noise gave him for his muscular energy and irritated feelings. He clearly 
treated the tin plates as if they were the " villains " that had been annoying 
him. The great difiiculty was to provide him work enough, he got through 
it so quickly. From that day to this, now eight years, he has been one 
of the most useful members of our community. If he has a fight, it is 
usually on Sunday. He still has the delusions of suspicion, but they are 
not all-powerful in his mind as they were, and his countenance is less 
expressive of fierce passion. He has got to believe now he has some 
friends, and that mollifies him. 

Patients in this condition of morbid suspicion attach delusional impor- 
tance to simple acts, e.g.^ a man who got some porter for his health wrote 
me the following letter : " Sir, I find by the report printed in the papers 
that you date your appointment as physician-superintendent here on the 
first day of Aug. 1873. Who then justified my porter test?" He im- 
agined that I was testing his mental state by the porter. I had a clergy- 
man once, D. T. B., under my care, who fancied that a conspiracy had 
been got up against him to put him out of every curacy he had held, 
and to prevent him getting a living, that the bishop had been concerned 
in this, and of course magistrates and authorities had refused him redress. 
Here is part of a letter of his : " My dear Dr. Clouston, I have oftener 
than once heard of your welfare, which I hope will go on prosperouslv 
so long as you are the true and faithful servant of God, though no further, 
as I told you. My state of outrage and wrong you know well or better 
than I do, for all to me is a complete mystery beyond what I do really 
know and have been compelled to feel. In places of this kind there is 
so much 'pantomime,' so I pay no attention to such nonsense. I have 
received no redress or improvement wliatever ! ! AVhat part you have 
taken in the Avrong I am suffering gon, know. There are and liave been 
several nice vacancies, one of which will suit me, though any parr of 



198 STATES OF FIXED AND LIMITED DELUSION. 

England, so as to be far off the atmosphere of asylums^ will suit me. I 
am in constant expectation of 'freedom,' 'compensation,' and a 'benefice' 
of my own. I have merit and purity enough for a bishop" — and so on 
for many pages of complaint and morbid suspicion. By the way, you 
will notice that he underlines much of his letter. The late Sir Robert 
Christison once said to me that he could usually tell a man who labored 
under insane delusions by the way he unnecessarily underlined his letters, 
and there is much truth in the observation. 

The most painful of all the cases of delusions of suspicion are those 
w^here a husband becomes insanely jealous of his wife, and suspicious of 
her fidelity w^ithout reason. After the full development of such a case, 
it is easy to see that such suspicions are insane, by the exaggerated way 
they are put, and by the utter want of evidence ; but at the beginning 
they are most difficult and unpleasant. I have now a lady in the asylum, 
D. T. C, quiet in manner, ladylike, and almost rational, who showed her 
insanity first by going to her clergyman and making a confidential report 
to him that her husband had given her syphilis, and he was accordingly 
at once summoned for ecclesiastical censure by the kirk-session of his 
church. Being a sensitive, nervous man, this had an extraordinary 
effect on him. From being fond of his wife, he suddenly conceived a 
hatred of her, believing that it was a deliberate plot to ruin him. Though 
other symptoms of insanity developed themselves in her, he never to his 
dying day could be made to believe that the syphilis delusion was any 
symptom of insanity on her part, but looked on it as simply wickedness. 
In her case the nature of her delusion seemed to be determined by the 
fact that she had a chronic uterine tumor, the uneasy sensations connected 
with which seemed to have suggested it. You should always look for 
bodily causes of delusions. I was once sent for in great haste, as a 
geentleman, D. T. D., was said to be killing his wife. I found a most 
respectable man, of first-rate business capacity, who had made a large 
fortune, and was still doing business, and who was reputed by the world 
at large to be perfectly sane, making the most outrageous allegations 
about his wife, and saying she had been unfaithful to him. I soon found 
that those accusations were of necessity insane delusions. He had seen 
her wink to scavengers as she passed them. He had met her just parted 
from a laboring man, with whom she had had connection under a wall, etc. 
I have now in the asylum two quiet, rational-loooking men, whose chief 
delusion is that their wives, both women of undoubted good character, 
have been unfaithful to them. Keep them off that and they are rational. 
On that subject they are utterly delusional and insane. They, like most 
such cases, are incurable. 

As an example of a perverted sensation or a local pain causing a 
delusion, I have now a gentleman, D. T. E., with disease of the rectum, 
who maintains that people come at night and commit sodomy. 

It is not uncommon to find women of middle-life with the combined 
delusions that certain men want to marry them, but that other people are 
preventing this. Clergymen are the most frequent objects of this most 
undesirable fancy. I have met with at least a dozen cases in all ranks of 
life of this kind. The subjects of it are usually not marriageable 
or attractive-looking persons. I shall show you a one-legged dressmaker 



STATES OF FIXED AND LIMITED DELUSION. 199 

of forty, D. T. F., with certainly no personal charms, who went to her 

clergyman and asked him to "proclaim" her and Mr. in church. 

On inquiry, he found the gentleman to be proclaimed had never spoken 
to her. He sat opposite to her in church, and she said he looked at her 
in such a significant way that she knew he wanted their banns proclaimed. 
D. T. F. said it was all owing to a scheming neighbor that she was not 
married to Mr. . 

A morbid feeling of fear is often associated with that of suspicion, 
especially in the cases that have arisen out of melancholia. I have 
a patient who is afraid if I take out my handkerchief, that it means 
something evil towards herself, who is constantly saying "Now, doctor, I 
know you are going to do something to me, what is it to be ? " 

It is common for patients with monamania of suspicion to conceal their 
delusions, except to intimate friends or near relations, for a long time, 
even for years, and when asked about them to deny that they believe 
them. We had a gentleman in Morningside (D. T. Gr.) once, who was 
full of morbid suspicions, believing that some of the people about him 
were other persons altogether, and that he was at times in danger of his 
life from poison. Yet for many years he never told these things to any 
person but one fellow-patient. Unlike the majority of such cases, he 
was to most persons a pleasant man ; his social instincts were strong, he 
was fairly happy, going all about ihe country on fishing excursions, and 
enjoying a joke and good story immensely. Before his death, when his 
brain disease had advanced, he was not so reticent about his delusions. I 
have now two patients, D. T. H. and D. T. I., who on their first admis- 
sions I had to discharge, because they denied their delusions so strenu- 
ously. In fact, D. T. H. was twice discharged for that reason. Yet 
they both labored under most insane suspicions, that the people in their 
houses and the streets annoyed them, and wanted to kill them. When- 
ever D. T. H. got a glass of Avhiskey, these delusions at once came out. 
On one occasion the second medical certificate for his admission could not 
be got, and he was tried before the Sheriff for threatening language. I 
had to say that I believed him to be insane, but that I had no proofs of it 
from himself That was deemed sufficient, and he w^as committed to the 
asylum. I have another patient who has been four times in an asylum, 
and while there, has never uttered one insane suspicion, though full of 
these about his wife, and really most dangerous to her. 

There are cases of monomania not to be classified under those three 
headings. I have, for instance, a man in the asylum, D. T. K., who for 
ten years has never spoken a word, but who I may say in all other 
respects behaves sanely, showing no symptoms of morbid pride or 
suspicion. He is about the best joiner Ave have. We know he has 
a delusion which prevents him speaking, but Avhat it is we can't find out. 
If he Avants instructions about his Avork, he Avrites, but nothing Avill 
induce him to write why he won't speak. There are certain patients, too, 
who simply express delusions as to the identity of those about them, 
without any suspicious, fearful, or persecuted feeling. l''hero is, indeed, 
a great variety in the symptoms of those Avho labor under delusional 
insanity. 



200 STATES OF FIXED AND LIMITED DELUSION. 

Proportion of Cases of Monomania. — At the close of the, year 
1881, there were eight hundred and twenty-two patients of all classes in 
the Royal Edinburgh Asylum, and of these eighty-seven were cases of 
delusional insanity, viz. : thirty-five of grandeur, fourteen of unseen 
agency, and thirty-eight of suspicion. Of the eighty-seven, forty-eight 
were men out of the four hundred and twenty-one male patients, so that 
the proportion in the two sexes did not differ much. There were more 
cases of monomania of pride and grandeur among the women than among 
the men, twenty to fifteen; while of suspicion there were twenty -five 
among the men to only thirteen among the women. I found one marked 
phenomenon in the natural history of delusional insanity. Out of one 
hundred and twenty patients of the higher classes socially, all with edu- 
cated brains, and many of them of old families, there were twenty-three 
cases of monomania, or about one-fifth of the whole, while among the 
five hundred and fifty-four pauper patients there were only forty-four 
cases of this variety of mental disease, or only one-twelfth of the whole. 
The one hundred and fifty-eight private patients of low^er social class were 
intermediate, and had twenty cases of monomania, or less than one-seventh. 
It would seem, therefore, that delusional insanity is most apt to occur in 
brains of the highest education. 

Diagnosis of Monomania. — I had a woman sent into the asylum 
lately who told me she was the mother of God. We had no history of 
the case at all. There was no general exaltation, no excitement, and no 
depression apparent. Was not that a case of delusional insanity ? Not 
in a correct use of the term, for the woman gradually passed into an 
attack of simple mania, ceasing to express this particular delusion after a 
few days. Therefore, you must always take into account the fixedness of 
the delusion or the delusional state, and the time the patient has suffered 
from it. Many maniacal and melancholic patients begin by expressing a 
single delusion, or exhibiting a single delusional state as the commence- 
ment of their general disease. I have met with plenty of cases, too, 
where from the very subacuteness of the mania or the melancholia, the 
symptoms of general exaltation or depression were not very evident, and 
a delusion stood out as apparently the disease, and yet the patient soon 
recovered. And as patients are recovering from mania and melancholia, 
they often exhibit delusional conditions for a long time after the general 
exaltation or depression has passed off. I had a patient who had an 
attack of acute mania lasting for three months, and after that, though 
quiet, industrious, and rational on most subjects, he believed his food was 
poisoned for twelve months. He then gradually ceased to believe his food 
was being poisoned, but he believed that it had been poisoned before for 
twelve months longer. I classify such a case as one of acute mania, not 
of monomania of suspicion. By the way, a patient's belief in the 
reality of his former delusions is not at all uncommon. A man says ''no 
one annoys me now, but I was subjected to persecution at home and 
when first I came into the asylum." I should not keep a man in ?n 
asylum, or count him a monomaniac, or even reckon him as legally 
insane, merely because he believed in the reality of his former delusion, 
if he had ceased to believe in their present existence, any more than 
I should count a man insane who could not get rid of the impression that 



STATES OF FIXED AND LIMITED DELUSION. 201 

the events of a dream had really taken place. The two chief things to 
be kept in mind in the diagnosis of monomania are : 1. Not to call any 
disease by that name that has not existed unaltered for at least twelve 
months. 2. When there exists along with the delusional condition any 
general brain exaltation or excitement, or any general depression, not to 
call it by that name till those have passed ofi'. 

Origin of Monomania. — It arises in at least four different w^ays in 
different cases. 1. It is a gradual evolution out of a natural disposition, 
a proud man becoming insanely and delusionally proud, a naturally 
suspicious man passing the sane borderland with his suspicions. From 
going over our cases I find about one-fourth of them arose in this way. 
It is the most common origin of the disease. There is usually a 
hereditary predisposition to insanity in those patients. . The disposition 
may in fact be regarded as the nervous diathesis out of which the mental 
disease springs. 2. It remains as a permanent brain result and damage, 
after attacks of mania and melancholia, especially the former, from which 
the patients recover up to a certain point, but no further. This is the 
origin of about one-sixth of the cases. 3. It arises from alcoholic and 
syphilitic poisoning of the brain and body, from traumatic injuries of the 
brain, or sunstroke, or from gross lesions, such as embolic sufferings. 
This seems to me to be its origin in about one-fifth of the cases. Such 
have usually the delusional insanity of suspicion or unseen agency. They 
are the most dangerous class of monomaniacs on the whole. 4. Most of 
the remainder, comprising over one-third of the cases, seemed to me to 
arise either out of perverted organic sensations caused by constitutional 
diseases characterized by lack of trophic power and brain anaemia, notably 
tuberculosis, or out of perverted sensations from local diseases misinter- 
preted by the brain, as in the woman with cancer of stomach. As a 
matter of fact, a very large proportion of the cases of monomania of 
suspicion die of phthisis pulmonalis. Any man with an ansemic, ill- 
nourished brain, is apt to be morbidly suspicious. 

Legal Importance of Insane Delusions. — Delusions are often of 
small clinical import, but are always of the highest value as a test of in- 
sanity from the lawyer's point of view. Therefore I advise you to bring 
them in always, if they exist, in signing certificates of insanity, in medico- 
legal documents, and in giving evidence before courts of justice. But 
you must remember there are harmless and dangerous delusions ; and if 
a delusion is obviously harmless, and does not bulk largely in the patient's 
life or affect his conduct, the law scarcely recognizes it as unsoundness of 
mind at all. It is quite impossible to distinguish scientifically between 
some vain or proud men, who dress and behave in an absurd manner, but 
do nothing needing interference with their liberty, and the man who 
thinks himself the son of George the Fourth, claims property that does 
not belong to him, and is therefore shut up in an asylum. There are 
plenty of persons doing their work in the world well, and yet they labor 
under monomania of pride or suspicion in a mild form. The now 
famous case of Mr. Wyld, who held an important Government ofiice, and 
did his work well all his life, and yet had labored under the delusion of 
grandeur, that he was a son of George the Fourth, and left all his money 
to the town of Brighton, because that monarch had been fond of that 



202 STATES OF FIXED AND LIMITED DELUSION. 

place, is one in point. He was held to be sane in everything he did but 
his will-making. I am constantly consulted by their friends about the 
insane delusions of persons who do not show them to anybody but their 
near relations, and continue to do their work and occupy responsible 
positions. I now know in Scotland lawyers, doctors, clergymen, business 
men, and workmen, who labor under undoubted delusional insanity, and 
yet do their work about as well as if they had been quite sane, though 
they are not such pleasant people as they would have been if sane, espe- 
cially to their relatives. 

Treatment of Delusional Insanity. — At the beginning, when 
there is a chance of the delusions not being quite fixed, there are two 
indications for treatment. The first is change of scene, circumstances, 
company, and occupation, wdiich can best be done by travelling about. 
The mind may be sometimes diverted from morbid tendencies in that 
way. And while this is being done, the second indication should be 
carried out, which is to correct and cure bodily disorders, to treat con- 
stitutional diseases like tuberculosis and syphilis and anaemia by suitable 
means, and to remove every bodily cause of convolutional disturbance, to 
withdraw objects of suspicion, and to bring up to the highest possible 
mark the nervous and bodily tone. By this means there is no doubt that 
some cases, especially those characterized by morbid suspicion, can be 
cured, even after they have existed for years. I have even seen a marked 
case of monomania of grandeur get better. A man who for more than a 
year fancied himself the Duke of Kilmarnock, got quite well, through im- 
provement in his bodily health, and working in the asylum garden. In 
a few cases with hallucinations of hearing, the continued current through 
the brain has seemed to do good. But for the confirmed monomaniacs of 
all sorts, who will insist on carrying out their ideas, an asylum is the 
only possible place of care. Dr. Charles H. Skae cured a case of mono- 
mania of suspicion caused through an injury to the head by trephining. 

Prognosis. — The prospect of recovery is certainly very bad in cases 
of delusional insanity that have lasted for over a year, but one is surprised 
sometimes by occasional recoveries after many years. There is a tendency 
to mental enfeeblement as time goes on. Many cases end in complete de- 
mentia after a few years, and in most the intensity of the conviction of 
the delusion, and the aggressiveness with which it is put forward, tend 
to diminish as time goes on. Most monomaniacs live long, all but the 
cases of morbid suspicion, who, as I said, mostly die of phthisis. 

Prophylaxis. — I think something can be done in those who are pre- 
disposed towards delusional insanity by their nervous diathesis and heredi- 
tary predisposition to the neuroses alone or combined with a heredity to 
consumption, towards counteracting the morbid disposition. While the 
reasoning power still holds its sway, it may be used in deliberate attempts 
to reason a man out of his morbid tendencies. I think I have seen a man 
in this way, and by not allowing himself to dwell on morbid thoughts and 
feelings, keep in check a morbid disposition. Good principles and good 
habits of life help greatly in the same direction. The occupation may 
be helpful, too, in counteracting it. I have often seen monomania of 
suspicion arise out of a suspicious, reserved temperament in young men, 
through the thoughtless and cruel small persecutions and annoyances of 



STATES OF FIXED AND LIMITED DELUSION. 203 

fellow-clerks and fellow-workmen. Human nature is not tender or con- 
siderate towards such weaknesses. I have certainly seen a proud dis- 
position become a monomania of pride through the injudicious pamperings 
and foolish adulation of female relations, and the encouragement of such 
a person in occupations and schemes beyond his capacity or means. No 
doubt temperate habits in all things are very prophylactic for the kind 
of brains I am now describing. I think I have seen cheerful family life 
cure a commencing delusion of suspicion. Association with their fellow- 
men is good for all persons predisposed in this way, provided they can 
get suitable company to associate with. To be suitable, it needs often to 
be opposite and complimental. In all persons predisposed to delusional 
insanity, the social instincts are apt to be rudimentary, and need develop- 
ment. There is no class of the insane who, on the whole, show their 
morbid tendencies at an earlier period of life than the monomaniacs, and, 
therefore, some of them can be prevented, the brain being still plastic. 



LECTURE VII. 

STATES OF MENTAL ENFEEBLEMENT {DEMENTIA, AMENTIA, 
PSYCHOPARESIS, CONGENITAL IMBECILITY, IDIOCY). 

We use tte term ''mental enfeeblement " not in its wide and popular 
sense, meaning any mental weakness or disease whatever, but in a special 
and scientific sense. It may be defined as "a general weakening of the 
mental power, comprising usually a lack of reasoning capacity, a diminu- 
tion of feeling, a lessened volitional and inhibitory power, a failure of 
memory, and a want of attention, interest, and curiosity in a person who 
had those mental qualities and lost them, or has come to the age to have 
them and they have not been developed." There are two great physio- 
logical periods of mental enfeeblement, viz., in childhood and old age. 
Consider the condition of a child of two as to reasoning power. There 
are many words indicating a lack of mental power that have two mean- 
ings, a pleasant or an unpleasant one, according as they are used in refer- 
ence to a child whose mindlessness is physiological, or to a man in whom 
it would be morbid. What more charming than " prattle," " artlessness, " 
" childishness," " innocence," as applied to a child ? But, said of a man, 
they mean "chatter," "silliness," "want of sense," or "unwisdom." 
If the brain development is arrested before birth or in childhood, we have 
congenital imbecility and idiocy — Amentia. Dotage must be reckoned 
as natural at the end of life. It is not actually the same as senile de- 
mentia, but there is no scientific difi'erence. Mental enfeeblement, both 
in judgment, feeling, memory, and volition, frequently occurs in and after 
bodily diseases, especially after fevers. It also always occurs in the pro- 
cess of starvation to death. It frequently is seen after the exhaustion 
of long journeys, great exertions, severe campaigns, and great mental 
tension, strains, or efibrts, such as business crises, sieges, etc. It also 
occurs after sudden or great emotional shocks, such as loss of children. 
Now, in all these cases the actual psychological condition may be the 
very same as in patients laboring under mental diseases proper, or tech- 
nical insanity. Yet we do not practically reckon them in that category, 
except they are unusually severe or very lasting. Still, the student of 
brain function and medical psychology, as well as the practical physician, 
finds a study of all those conditions of mental enfeeblement most profit- 
able. 

The conditions of mental enfeeblement that are ordinarily reckoned 
among mental diseases may exist in every possible degree, from the 
merest dulling of the keen edge of certain mental faculties up to com- 
plete loss of intelligence, feeling, and memory. One man may be just 
so much altered that his friends say, "He is not the same man he once 
was," and another may not be able to comprehend or ansAver the simplest 



STATES OF MENTAL ENFEEBLEMENT. 205 

questions or to recollect his own name. A clever man may be left in 
such a condition that in his dementia he is more intelligent than another 
stupid man. A man may, while he is not energizing mentally, seem as 
other men are, or as he once was ; but, when he comes to think, or act, 
or work, it is seen that he cannot do so as before. In most cases all the 
mental faculties are enfeebled together, either pretty equally or one suf- 
fering more and another less. In a few cases some mental faculties are 
left almost intact, while others are almost destroyed. I have a patient 
now whose brain was once a most energetic and subtle one and his mem- 
ory extraordinarily retentive, who talks quite rationally on all kinds of 
subjects, if they are suggested to him or if you "draw him out," and 
argues most correctly, but who never originates anything, is utterly help- 
less in action, and who cannot tell you the day of the week or what he 
had for breakfast. The originating power of mind, spontaneity of thought 
and feeling, active vigor of will that highest quality of all, are always 
diminished or lost in dementia. I know a man who when well always 
impressed those with whom he came in contact as being a leader of men, 
and who now, after an attack of mania, has lost the power of producing 
that impression. As one of his friends said to me — "I was always 

afraid of Mr. , and never could be familiar with him. Now that's 

gone." Pathologically and psychologically, the mental state of such a 
man is the same in kind, if not in degree, as the absolute dementia of 
asylums. Yet, of course, the degree makes a great difference from a 
legal and social point of view. A man's mind may be slightly weakened 
and yet he may enjoy his personal freedom, and another man who is 
more affected has to be deprived of this ; but there is no line of demar- 
cation, and no test to distinguish between technical sanity and technical 
insanity in dementia. 

It must be remembered that in all insanity there is an element — often 
a strong one — of mental enfeeblement pure and simple. Most cases of 
exaltation have enfeeblement of judging power as well as of feeling. 
Many cases of melancholia are enfeebled as well as depressed. 

A typical case of dementia is one affected as this young man E. A. is. 
As he came into the room his walk was hesitating and almost shuffling, 
and you see his bodily attitude is one of diminished muscular and 
nervous vigor. He stoops, his face is vacant-looking, he has no curiosity 
as to where he is coming, or as to what I am saying about him ; when I 
ask him his name he tells it, but cannot tell the day, or month, or year. 
In asking him questions, I have to adopt means by speaking loud and 
sharply, or by patting his arm, to rouse his attention to listen to me. 
His mental operations are slow^ as well as weak, for it takes his brain 
long apparently to take up impressions from the senses, and still longer 
to evolve the outward process of speech in response. When I ask him 
"where were you born ?" he says, after a minute, " Oh yes, I think so." 
When I ask him "who is that?" pointing to a student, "that's my uncle 
John." "What place is this you are living in?" "I don't know." 
"Did you ever ask any one what place it was?" "Yes." "Are you 
sure?" "No." " How long have you been here ? " ''This morning." 
(He has been here six years.) He cannot reason, he has almost no atVoo- 
tions, caring for no one, showing no pleasure in seeing his relations. He 



I 



c' 



206 STATES OF MENTAL ENFEEBLEMENT . 

has no wishes, hopes, fears, or memory. He does not resist anything 
and has no choice as between any two things. He has no fineness of 
feeling, no "tastes." His habits would become dirty and degraded if not 
looked after. Looked at from the purely bodily point of view, he has 
no keen appetite at all even for food, for he has been several times for- 
gotten in the garden over meal-times, and hunger did not bring him to 
dinner. He has no proper sexual appetite, though he masturbates in an 
automatic way. His temperature is about a degree and a half below the 
normal, his circulation poor, his hands blue and cold in chilly weather, 
his muscles flabby, his common sensibility much diminished, for you see 
pricking with a pin does not rouse him much. His digestion and the 
action of the bowels are good and regular, and the sleep power of his 
brain is perfect, in fact he would sleep too long if allowed to. There is 
a good deal of flabby fat on his body. Sores are slow in healing, and 
when he catches cold he scarcely ever coughs, though there may be much 
bronchial irritation. The reflex action of the cord is diminished, though 
the tendon reflex is normal. Last of all, and most important, that power 
of action and power of coordination of those marvellously innervated 
strands of muscles in the face that give "expression" to the face, seem 
to be utterly dulled and diminished, and the eyes are expressionless. It 
is clear that all the higher qualities of his brain are gone, and that even 
the lower qualities are much enfeebled. He is now demented ; but he 
was once an intelligent, educated man, who had an attack of acute mania, 
and was left, after that had passed away, as you see him. 
There are five chief kinds of dementia : 

1. Secondary {Ordinary or Sequential) Dementia^ following mania 
and melancholia or other insanity. 

2. Primary JEnfeehlement {Congenital Imhecility, Idiocy^ Amentia, 
Cretinism)^ the result of deficient brain development, or of brain disease 
in early life. 

3. Senile Dementia. 

4. Organic Dementia, the result of gross organic brain disease. 

5. Alcoholic Dementia, following the long-continued excessive use of 
alcohol. As the last three varieties will be described under the headings 
of the senile, paralytic, and alcoholic insanities, I shall not further refer 
to them here. 

As every variety of dementia is incurable, and as the medical profession 
outside of public institutions has little to do with its treatment or manage- 
ment, I shall devote little time to this variety of mental disease. 

Secoxdary Dementia. — This always follows and is in a w^ay the result 
of more acute mental disease, such as mania and melancholia, and there- 
fore may be called sequential. It is the most characteristic, the most 
common, and the most important of all the kinds of mental enfeeblement, 
so that when you hear of a person laboring under dementia, it is usually 
this that is meant. It is dementia par excellence, therefore. It is the 
goal of all chronic insanities. 

When a condition of morbid mental exaltation, especially when this 
has been acute mania, has existed for a long time, we find that the over- 
action usually causes a tendency to mental weakness as the exaltation 
passes away, and that this is apt to be left as a permanent brain condi- 



STATES OF MENTAL ENFEEBLEMENT. 207 

tion. This is dementia. The same tendency is seen, but to a less degree, 
as the result of a prolonged condition of mental depression. This is the 
termination we most of all dread in acute insanity. All mental diseases 
when long continued tend towards dementia. When the matter is looked 
at pathogenetically it might be thus stated. For the production of most 
cases of mental disease we need a morbid neurotic heredity, or a prolonged 
cause of irritation or exhaustion. Then comes an exciting cause of dis- 
turbance strong enough to convert this tendency, this potentiality, into 
an actual disease, and a severe outburst of abnormal action occurs in the 
brain convolutions. The symptoms of this are the maniacal exaltation, 
or the melancholic depression. The abnormal action means abnormal 
nutrition as well as abnormal energizing. This, like all long-continued 
abnormal nutrition, tends injuriously to affect the minute and delicate 
neurine structure, the capillaries, the lymphatics, and the packing tissue 
of the gray matter of the convolutions. It even affects, as we have seen, 
the structure of the surroundings of the brain, the pia mater, the large 
vessels, the arachnoid, the cerebro-spinal fluid, the dura mater, and the 
calvarium. When this storm of morbid action at last passes off or ex- 
hausts itself, the cells have become so damaged that they are no longer 
fit to become the vehicles of normal mentalization — their nutrition, their 
storage of energy, their receptive and their productive power being im- 
paired. The mental result of this is enfeeblement or dementia. Some- 
what the same thing occurs in coarser forms in all the coarser tissues and 
organs, e. g.^ the permanent damage to locomotion that results from long- 
continued rheumatic inflammation of a joint, to digestion from prolonged 
over-stimulation of the stomach, to sight from the intense lights of the 
desert or the Alps, to hearing from the continuous clang of an iron ship- 
building yard. You will remember, how^ever, that from the very begin- 
ning there was probably a tendency towards that weakening of the mental 
functions of the brain which we call dementia. The great difference in 
effect between partial loss of function in the brain convolutions, and in 
any other organ of the body, is that in the former case the man dies to 
all intents and purposes, socially his right to liberty is gone, and his place 
among his fellow-men is taken by another. 

The following is a typical case of secondary dementia. E. B., a hand- 
some, well-developed, intelligent, and well-educated young woman, whose 
mother was insane, her sister a woman that "no one could live with," 
and a brother a confirmed drunkard, had, at the age of twenty-four, a 
cross in a love affair. At first she was depressed in spirits for a few 
months, then she took to a morbid eccentric religionism, and in six 
months became acutely maniacal. She remained so for a year. Xt the 
end of that time her whole appearance and expression of face were so 
different from the attractive girl she had been that her friends scarcely 
recognized the same person. Her face, that "mirror of the soul," ex- 
pressed no doubt the fancies and the passions that were evolved in her 
morbid brain, but there was also a vacancy and a physiological degrada- 
tion very manifest. About that time she began to sleep bettor, then to 
eat better, then to talk and scream less, then to be able to sit still longer 
and control herself more. This process of gradual quiescence went on 
for six months, with occasional spurts of exaltation, and short relapses 



il 



208 STATES OF MENTAL ENFEEBLEMENT . 

into active mania. By that time she was getting fat, sluggish, devoid of 
interest in anything, and with no emotion. She did not ask for those 
who had been dearest to her, or exhibit any pleasure when they came to 
see her. She often laughed and talked to herself Her speech and con- 
duct were best described as very " silly." Her memory seemed gone. 
All that education had done for her brain seemed to have disappeared, or 
could only be brought out in disjointed, incoherent scraps. The nameless 
charms of dress and manner and behavior of a bright young lady had ab- 
solutely disappeared. She was slovenly and not over cleanly, showed 
few likes and dislikes, no will of her own. Her face was vacant, her 
eyes expressionless, her motions slow and wanting in purpose and vigor, 
and her nutrition flabby. But she slept well, she ate very well but 
with little choice of foods, her dio;estion was ojood, her bowels reo;ular, 
and her menstruation, which had ceased during the whole of the maniacal 
period, became regular. She is in fact dead to mental life in any proper 
sense, and so has remained now for many years, and so will remain till 
she dies of some disease that will not necessarily be a brain disease at all. 
Her chances of life are probably below those of a sound person at her 
age, but she may live long. These are the cases that form the bulk of 
the old inmates of asylums, and about whom their friends say, they seem 
to outlive all their sane relations and friends, because they are free from 
the worries and cares of life, and live a regulated existence under medical 
rule. 

In certain things E. B. did improve after the first two years. Her 
brain was subjected to a reeducation of a simple kind, but its capacity 
for this was limited. It had no power of acquiring any sort of high 
attainment in anything. She was taught to dress herself more neatly, 
to do a little simple work, to observe certain hours for meals, etc. Curi- 
ously enough certain mechanical achievements in which she had been 
well educated, so that they had become the automatic property of the 
ideo-motor brain centres, came back to her easily, and were well done. 
Such were certain kinds of ladies' work, and sewing. It was found she 
could play some of her old tunes on the piano, but the music was me- 
chanical. All the life and soul were out of it. She could not be taught 
the simplest of new tunes, no new stitching, no new dance steps. Every 
now and again she had a slight return of the maniacal exaltation, begin- 
ning usually at a menstrual period, and at the very beginning of one of 
these she would look and act more like her sane self than at any other 
time. She is placed under the control of social inferiors, and she does 
not resist. She lives in the asylum, and she does not ask why. She 
has no money, and she does not seek it. She forms no attachment, and 
she associates with the most incongruous people without feeling it. 

This is the type of all the cases of secondary dementia in its causes 
and symptoms. But there are, of course, great variety in the details of 
the clinical pictures. Attacks of melancholia may be followed by de- 
mentia, but this is not nearly so common as in the case of mania, except 
in the senile cases. Nothing more conclusively shows that conditions of 
depression are essentially less profound departures from mental health 
than conditions of exaltation, than the lesser tendency to dementia after 
the former. When it does occur it is a less complete dementia than 



STATES OF MENTAL ENFEEBLEMENT. 209 

occurs after mania, and is nearly always tinged with a melancholic cast. 
Out of one hundred cases of dementia taken at random, whose histories 
I know^, only twenty followed melancholia. All sorts of partial dementia 
occur. I have many patients in the asylum who look like other people, 
who converse with you rationally when you talk with them, and have no 
delusion, but they have no initiative, no originating- power, no active 
desires, no power of self-guidance, or resistive capacity. I sent such a 
man out of the asylum lately, and he just sat down at home, would not 
work, would scarcely get out of bed, cared nothing for cleanliness and 
the decencies of life, and only earned ten shillings the six months he was 
out. Some persons in this state do some work in the world outside 
under suitable, interested, and kindly guidance. Sometimes a man is 
left after a maniacal attack mentally twisted, or has a curious mixture of 
enfeeblement and obstinacy. I know a gentleman who once had an 
attack of mania, and who now shows a mild dementia chiefly in either 
defying or being unconscious of the conventionalities of life. He goes 
about the streets often in a dressing-gown and slippers, he pays no defer- 
ence whatever to ladies, he eats at irregular hours, is " never to be de- 
pended upon " in anything, and yet he manages his affairs and seems 
happy in a way. In some cases a man shows mild dementia by slight 
degradations in his habits and feelings. I know such a man who is 
simply not so sensitive as he once was, not so particular in small things, 
is content with w^orse -fitting clothes, and is not so neat and clean in his 
ways. I know another case where it shows itself by what his friends call 
excessive laziness. He will not walk or work, or do anything in fact, 
but sit in the house and smoke. I know many cases where it shows 
itself in deficient inhibitory power over the appetites, the patients taking 
to drinking and sexual immorality. In other cases they simply sink 
into a lower social stratum, and evidently are more happy there than in 
their own. Such cases are commonly reckoned as being examples of 
mere eccentricity, but they are scientifically cases of partial and limited 
enfeeblement of mind. 

There are certain things that are of the greatest importance in relation 
to secondary dementia. The first of these is undoubtedly the length of 
the attack of the acute primary insanity. The risk of dementia is in 
direct ratio to the length of the maniacal exaltation. This does not 
quite apply to melancholic depression, the existence of which for long 
periods is not so damaging to convolution function. Beyond a doubt 
there are some cases that become demented after only a few weeks of 
maniacal excitement, when, in fact, it is clear that the tendency to it was 
present from the beginning, and when it was an inevitable doom of their 
brains. These are the brains which seem to have innate energizing 
power in them to last only for so many years, and then they fiiil and die 
as to their higher mental functions. Of course, it may be asked — How 
do we know that this is not the case in all those that become demented, 
without reference to the preceding mania at all ? May not the mania 
simply be one incident on the road to inindlessness, and not the cause of 
the latter at all ? It is right to ask such questions. On the whole, tlio 
facts of a o;i'eat number of cases make one conclude that a maniacal 



to' 

14 



210 STATES OF MENTAL EN FEEBLEM ENT . 

attack does damage the brain convolutions, and that the longer it lasts 
the more likely is that damage to be permanent. 

2. The character of the primary attack influences the tendency to 
dementia as well as its duration. The more acute the attack, the greater 
tendency there is to subsequent mental enfeeblement. The acutely 
delirious state is the most damaging of all, no doubt. But to this rule 
there are many exceptions. I have now a case quite demented where the 
primary maniacal attack was very mild — only amounting to simple 
mania, and that lasting but for a month or so. Then enfeeblement 
showed itself, and slowly progressed, till in four years there was deep 
dementia. I have even seen a few cases where a mental enfeeblement 
began ah initio without mania, without melancholia, without gross organic 
disease or epilepsy or alcoholism. Such cases are very rare indeed, how- 
ever. We can usually get evidence of some symptoms of mania or 
melancholia if we have the means of ascertaining correctly the patient's 
state. The habit of masturbation may cause dementia as a primary 
mental disease in young people with a strong neurotic heredity, without 
preliminary mania. But the great difference in the onset of the secondary 
or ordinary dementia from that of the organic dementia is the existence 
of a preceding attack of mania or melancholia in the former and its 
absence in the latter. 

3. The number of previous attacks is no doubt of the utmost impor- 
tance in the causation of dementia, except in the case of those typical 
examples of alternating insanity called folie circulaire, which I have 
described. The case of D. B. (p. 175), whose brain has had over two 
hundred attacks of acute maniacal excitement in the last thirty-six years, 
and yet is not wholly demented, is a most striking example of the 
recuperative power of the brain convolutions. Speaking generally, the 
tendency to dementia increases in each successive attack. The relapsing 
tendency of adolescent insanity is to my mind an illustration of the two 
inherent tendencies in such brains — the one to mental recovery and life, 
the other to mental death. And we notice that the sooner the relapsing 
tendency stops, the more likely is the former result to occur. It often 
happens that after a first attack of insanity certain mental peculiarities 
are left, seen it may be only by the patient's near relations and intimate 
friends. He is not " quite the same man." Each succeeding attack that 
he has leaves him with more marked peculiarities or weaknesses, until the 
final irreparable break-down of dementia is reached. You will constantly 
be asked your opinion of a man who has once been insane, to hold 
appointments, to accept trusts, to contract marriage, etc. One must 
frequently give a guarded answer, and this, not only after examination 
yourself, but after most minute inquiry from disinterested friends who 
have seen most of him. I find it often more diflScult to pronounce a man 
sane and mentally competent than to pronounce him insane. There is no 
doubt that a man may fiilly and perfectly recover from attacks of insanity. 
They may leave not a trace behind them in any shape or form. I could 
point to hundreds of men and women who have been insane, and 
who now do their work as well as ever they did. It is a grave injustice 
to regard all men who have been insane as tainted and unfit to hold 
appointments of trust, though this is unfortunately a common prejudice. 



STATES OF MENTAL ENFEEBLEMENT . 211 

There is a risk, no doubt, but it would be, indeed, a terrible thing if 
mental disease were regarded as necessarily implying an incurable mental 
deficiency or a relapse some day. 

4. The fourth element that affects the occurrence of dementia, and 
that we have to take into account, is the heredity of the patient. The 
common opinion undoubtedly is, both among the profession and general 
public, that a strong family predisposition to insanity means a bad chance 
of recovery in any particular attack, in other words, a tendency to 
dementia. Now this is not true as a matter of fact. Strongly hereditary 
cases are the most curable of all, but they are most liable to recur ; 
though many of them are undoubtedly incurable from the beginning. A 
strong and direct heredity implies three things, (1) instability of brain, 
(2) liability to attacks at early ages, and (3) liability to a recurrence 
after cure. 

5. The fifth element in our prognosis is the age of the patient. A man 
who has youth on his side has a much better chance of coming out of a 
brain storm of acute mania unharmed ; but to disturb this calculation 
come in those cases of mental diseases, occurring at early ages, and in 
brains whose whole stock of mental protoplasm is exhausted in a few 
years instead of being sufiicient to last through the whole life of the 
body. As we shall see when I com^ to speak of senile insanity, we may 
have attacks of mania and melancholia in the advanced periods of life, 
when the brain is in the stage of decadence and the arteries are very 
diseased, recovered from altogether, or only leaving a mild senility. 

6. There is a state of mental weakness that frequently follows sharp 
attacks of mania and melancholia, which closely resembles dementia, and 
yet is quite curable. It is in reality a mild form of stupor, and I shall 
treat it under that heading. It is analogous to the stage of temporary 
exhaustion and reaction that follows all acute diseases. It is the period 
of functional rest but trophic activity, during which, through the vis 
medicatrix naturce^ organs that have been diseased heal, tissues whose 
nutrition has been disturbed eliminate morbid elements and become 
normal, and functions that have been altered or suspended resume slowly 
their activity. This period is of the highest importance for treatment. 
Rest, nutritives, tonics, sometimes stimulants, and counter-irritants are 
then indicated. It is the time for the use of the stimulatino- nerve tonics 
and vaso-motor stimulants, such as strychnine, quinine, phosphorus, the 
phosphates and hypophosphites, shower-baths, friction to skin, the inter- 
rupted and continued currents, Turkish baths, followed by brisk sham- 
pooing, and blisters to the back of the head. I have a man who had 
become dull, stupid, and lethargic after an attack of acute mania, and he 
" wakened up " visibly under such treatment. I had a young woman 
who had ceased to speak, rouse up and begin talking and working imme- 
diately after a blister had been applied to the back of her head. I had a 
man who roused up not only in mind but in muscular activity, and in vaso- 
motor force, his hands o-ettinii; Avarm instead of blue, under the use ot 
Parrish's syrup of the phosphates. This was stopped in a fortnight and 
he at once fell back. It was renewed and he picked up, and again 
stopped and he fell back. It was given continuously for three months 
till he recovered completely. 



212 states of mental enfeeblemekt. 

Primary Eneeeblement (Idiocy, Congenital Imbecility, Amen- 
tia). — I do not ^^ropose to say much about the conditions of primary 
mental enfeeblement, but rather to glance at a few of the most typical 
varieties. Ireland's^ definition is that " idiocy is a mental deficiency or 
extreme stupidity, depending upon malnutrition or disease of the nervous 
centres, occurring either before birth or before the evolution of the mental 
faculties in childhood." " Imbecility is generally used to denote a less 
decided degree of mental incapacity." In short, idiocy and imbecility 
are conditions of mental enfeeblement resulting from want of brain 
development before birth or in childhood. The mental faculties were 
never there, their organ being unfit to manifest them. In dementia, as 
we have seen, they were destroyed or enfeebled in a previously normal 
brain. It is necessary that medical men in practice should have a general 
knowledge in regard to this as to any other disease about which their 
opinion may be asked. It is well to bear in mind certain things in regard 
to idiocy. 1. That there are great varieties of the condition, both as to 
symptoms, causes, treatment, educability, and prognosis. 2. That the 
mental deficiency is always accompanied by bodily weakness of some sort, 
trophic, resistive, and motor, which can often be treated with good efi"ect 
by the ordinary resources of our profession. 3. That by heredity and 
physiological connection it is apt to be associated with scrofula, tubercu- 
losis, drunkenness, insanity, and crime. 4. That the main instrument of 
treatment must be a general bodily and mental education of a special 
kind, adapted to the physiological educability and potentialities of the 
individual brain under treatment. 

Congenital Imbecility. — This may exist in every degree, from the 
smallest amount of mental weakness down to idiocy. Here is a case : 

E. C, now twenty-five, of a family in which both drunkenness and 
insanity had occurred. When a child he was well developed, and 
apparently like other children, till he was about three or four years of 
age, when it was noticed that he was not so bright, not so imitative, and 
not so observant as a child at that age should be. Speech was long in 
coming and diflicult to learn. As he grew older he could learn almost 
nothing at school ; his school-fellows annoyed him, and he showed 
violent, ungovernable passion and violence. The faculty of inhibition is 
almost always weak in imbeciles, but they are not all passionate or ungov- 
ernable. At puberty he got much more difficult to manage at home, and 
all his weaknesses and peculiarities were thus more observable. Unfortu- 
nately he was not then sent to a special institution for the training of 
imbeciles. He could have been then taught much more than he now^ knows. 
In fact, I see no reason why he should not have learned some trade 
or mechanical work, and done it in a moderately efficient way. He got 
so irritable, and, when in a passion, so violent, that he had to be sent 
here about ten years ago. He has settled down into the life and routine 
of the place, is cleanly, tidy, and orderly in his habits, industrious 
in simple matters, such as bed-making, floor-washing, but is still very 
passionate and impulsive. He is happy and contented, and has no 
unfLilfilled ambitions or longings to satisfy. Look at him. He is fairly 

^ Idioc}- and Imbecility, by W. W. Ireland, 31. D. 



STATES OF MENTAL E NFEEBLEM ENT. 213 

developed. At ten yards' distance you would say lie was an ordinary- 
looking young man. When you observe him closely you see there is a 
weakness in his expression of face, a lack of mind in his eye, and a sort 
of shuffle in his walk, while all his movements lack purpose and concise- 
ness. When he smiles he looks silly, and his speech is rather defective. 
You see at once there is no force in him of any sort, motor or mental. 
When further tested, his memory is seen to be defective, he cannot tell 
you how much four added to four and two off is. He can write, but like 
a schoolboy. You see that he is unfit to guide himself, to manage his 
aifairs, to earn unaided his livelihood, or to resist any sort of temptation 
put in his way. He is in good bodily health, eats and sleeps well, enjoys 
simple pleasures like dancing, concerts, and juggler's entertainments, and 
may live long. 

E. C. is a good type of the most common form of congenital imbecile. 
There are others where one has much more difficulty in determining 
whether they shall enjoy civil rights and liberty, be allowed to marry, 
etc., being very near the minimum legally sane line. Such persons 
become the dupes of designing people, cannot resist temptation, or control 
natural desires, and often become the worst kind of dipsomaniacs. Some 
imbeciles show special talent in certain directions, some in music, some in 
drawing, some in imitation, some in^a kind of constructiveness ; some, who 
are of a criminal class, are bad and depraved from the beginning — are 
born imbecile criminals. As to treatment, the great things are, carefully 
to develop the body, to keep it always fat, not to give much animal food 
or stimulating diet, especially at puberty, to train in good habits — bodily, 
mental, and moral — to make their lives systematic and orderly, to avoid 
occasions of ill-temper, to punish justly and usually by deprivation of 
indulgences, to send to institutions for training and not to ordinary 
lunatic asylums till this is unavoidable. 

Congenital imbeciles may have attacks of maniacal excitement or 
melancholic depression — in fact, are subject to them. They may become 
dangerous and even homicidal ; they may, after an attack, have secondary 
stupor, or may become demented as compared with their primitive condi- 
tion. They are often terrible masturbators. 

Idiocy. — I find the most useful classification of idiocy is that of Dr. 
Ireland, as follows : 1. Genetous ; 2. Eclampsic ; 3. Epileptic ; 4. 
Paralytic ; 5. Inflammatory ; 6. Traumatic ; 7. Microcephalic ; 8. Hydro- 
cephalic ; 9. By deprivation of the senses ; and 10. Cretinism. 

Genetous idiocy is that variety which begins before birth. E. D. is a 
very unfavorable case. She is now twenty -four, and never showed any 
mental potentiality at all from the beginning. She showed no affection, 
no clinging to anyone in particular, not even like that of a dog to those 
who fed her and were kind to her. She has never had any understanding 
of anything, never could speak, always grunted in that animal-like way 
you hear, never showed curiosity, imitativeness, or power of attention. 
You see her body is squat and ugly, her temperature low, her palate 
acutely arched, and her teeth irregular and few in number. She has 
from childhood beaten her head with her hands, as you see her now doing, 
just as the gorillas beat their breasts in the African woods. Her face is 
utterly unhuman, hence such cases have been called theroid or beast-like. 



214 STATES OF MENTAL ENFEEBLEMENT . 

The evolutionists would find many proofs of reversion to conditions 
common in the lower animals in her. When you place a tumbler of 
water on the floor before her, you see she kneels down and laps it with 
her tongue. She has not a rudimentary sense of decency or sexual 
feeling. Such a case is beyond the reach of teaching or training of any 
sort. Nothing can be done but to feed and clothe her and keep her clean. 

The next case of E. E., is a much more hopeful subject. He, too, is 
a genetous idiot, and is small, ill-developed, rather deformed, bandy- 
legged, cold, feeble in muscle and trophic power, but he in a way 
understands some things you say to him, is always smiling, is gentle, has 
been taught to be cleanly and almost tidy. He has no sexual feelings, 
cannot read or write or count, and will probably die of consumption. 

The genetous form the largest class of idiots, vary greatly in the 
mental capacity present, and many of them can be trained in training 
schools, and made more human and comfortable. 

The eclampsic idiots are those whose brains have been injured, and 
their development afterwards retarded by convulsions at dentition. They 
are an unfavorable class as regards training. The damage done to the 
brain and its envelopes is usually demonstrable after death. 

I produce before you a whole series of epileptic idiots. Their charac- 
teristics are : 1. That they vary in mental condition very much according 
to whether they are taking fits or not at the time. 2. That the efiect of 
the constant recurrences of the epileptic seizures is such on the brain that 
it tends to lose the efi'ects of training and to deteriorate. 

Take this example of E. F., now sixteen, who has taken fits since he 
was a year old. At times he is gentle and teachable, and works in the 
garden, and enjoys life ; then he will have a few epileptic fits, and he will 
be stupid, dirty in his habits, and will forget all his training. After that 
he will be for a day or two irritable, violent, impulsive, and even danger- 
ous. He articulates in a childish way. He is getting worse, and will, no 
doubt, die some day in a fit or after a series of fits. I have seen the 
steady use of the bromide of potassium very useful in such cases, lessening 
the number of the fits and their severity, diminishing the irritability, and 
improving the nutrition. We have one boy here who is quite another 
being for the past four year under twenty grain doses three times a day. 

The paralytic form of idiocy is represented by this case of E. Gr., who 
was normal in body and mind till he was four years of age. He then 
had an apoplectic attack, and his left hand, arm, leg, and left side of his 
face and head are partially paralyzed, ill-developed, and the limbs 
shrunken, flaccid, and useless ever since. He takes sporadic epileptic 
attacks. He tries to articulate, but you cannot make out what he says ; 
he is restless, irritable, not very educable, weak, and cold. Such cases, 
looked at fi'om the motor point of view by the general physicians, are 
called cases of Essential paralysis of infancy. The degree to which the 
paralysis and the mental affection are found in different cases varies from 
sanity to idiocy, from the slightest weakness to complete paralysis, 
shrivelling, and shrinking of the limbs. The pathology of those cases is 
very interesting. Often the convolutions in the affected hemisphere are 
found damaged and atrophied, the lower ganglia and centres undeveloped, 
and one-half of the spinal cord, as well as the motor nerves from it to 



I 



STATES OF MENTAL ENFEEBLEMEN T . 215 

the affected side, atrophied or not developed. I have never been able to 
understand why cerebral apoplexies occur in infancy. I am inclined to 
think that they are often not effusions of blood, but vaso-motor spasms 
from neurotic causes affecting certain of the cerebral vessels, and resulting 
in trophic damage to the parts of the brain deprived of blood. 

The inflammatory idiocy results from the inflammations and sloughings 
that aff"ect the throat and ears in scarlet fever spreading inwards and 
damaging the brain. Certain portions of the organ are usually found to 
be hypertrophic in those cases. It is a very unfavorable variety. 

The traumatic variety is much like the inflammatory, or sometimes like 
the paralytic form, and results from falls and blow^ on the head. 

The microcephalic is a very interesting variety of idiocy. On the 
whole, the heads of idiots are smaller than those of sane persons, but 
there are many exceptions to this rule, and, as a matter of fact, the 
average sizes of the heads of idiots are as large as the minimum sizes of 
perfectly sane persons. Ireland says : " The size of the head gives no 
estimate of the comparative intelligence of the (idiotic) children." There 
is, however, a certain minimum size below which a head is incompatible 
with average intelligence. I believe a circumference of below eighteen 
inches means idiocy. Very typical microcephalics are rare, but, when 
seen, they make a strong impression. They look so impish and 
unearthly. They are usually active, alert, mischievous, imitative, 
intractable. I have no really good specimen, but E. H., with a head of 
eighteen inches in circumference, a small face, a small but perfectly well- 
formed body, an active, imitative way, and a restless manner, gives an 
idea of one. Her only deformity is a cleft and acutely arched palate. 
She just looks like a small dried-up woman, with small features and a 
most singular expression of face, and she smiles as if a baby was 
imitating the features of an old woman. Microcephalics should always 
be sent to training schools. They are often educable up to a certain 
point, and, if not educated, they are often little demons. Their muscular 
activity must find an outlet. 

The hydrocephalic variety of idiocy is very common, but I need hardly 
say to you that hydrocephalus with even enormous enlargement and great 
deformity of the head is perfectly compatible with sanity. It usually has 
a dwarfing and, often, a deforming effect on the body. A small head is 
no proof that there has not been hydrocephalus. 

E. I. is a good example of a hydrocephalic idiot. She is now ten, and 
is slow in her movements, very gentle and patient, sometimes cries and 
moans, as if she had an organic sensation of discomfort in her head. 
Her head is globular, the fontanelles raised, the temples projected. She 
looks unhealthy, has scrofulous glands, and a feeble constitution. Her 
temper is good. Slie is educable, and worth educating. I am going to 
have her sent from this to an imbecile training institution. Drs. Batty 
Tuke and Campbell Clark described very fully the condition of the brain 
in hydrocephalic idiocy. The former found enormous hypertrophy of the 
neuroglia, and the latter found a floating lobe or portion of brain, 
unattached to any other nerve tissue, which could never, therefore, have 
exercised nerve functions, yet it liad nerve cells and fibres in a priniirive 
form. 



216 STATES OF MENTAL ENFEEBLEMEXT . 

Idiocy may occur by depriyation of tlie senses only. The famous case 
of Laura Bridgman, who was blind, deaf, and dumb, and with an indis- 
tinct sense of smell, but with common sensation, through which Dr. 
Howe educated her brain, developed intelligence and emotion, and 
raised her from a condition of absolute idiocy to one of great mental 
capacity, is and will always be the classical case of idiocy by deprivation. 
She differed essentially from most other forms and cases of idiocy in 
having a brain well developed and apparently normal in all respects, 
except that its inlets and outlets were obstructed. Ordinary deaf-mutism 
is closely allied to idiocy, and is one of the hereditary neuroses. To me 
it is a physiological sin that marriages between such persons should be 
legal. 

Cretinism is an endemic disease occurring in connection with goitre in 
some valleys of mountain chains, such as the Alps, Cordilleras, and 
Himalayas, and not found here, so I need say nothing about it. It 
is very interesting from an etiological and pathological point of view, and 
has quite a literature of its own on the Continent. 



I 



LECTURE yill. 

STATES OF MENTAL STUPOK (PSFCHOCOMA). 

You will not find stupor put among the ordinary symptomatological 
varieties of mental diseases, along with mania, melancholia, etc. This I 
think is a mistake. The only objections to its being so placed are two — 
that it is not commonly a primary disease ; and that the word stupor 
does not imply to the lay or even to the medical mind any necessary 
mental disease at all, as they understand it. But these objections should 
not prevent us using the word to express in a correct scientific sense a 
morbid mental condition, which is dififerent psychologically and clinically 
from all other morbid mental symptoms, which, while it lasts, demands 
difierent treatment from them in many cases, and has a different course 
and termination. Stupor used in this strict medico-psychological sense 
may be thus defined : "A morbid condition in which there are mental and 
nervous lethargy and torpor, in which impressions on the senses produce 
no outward present effect, in which the faculty of attention is or seems 
perfectly paralyzed, in which there is no sign of originating mental power, 
in which the higher reflex functions of the brain are paralyzed, and in 
which the voluntary motions are almost suspended for want of convolu- 
tion al stimulus, but where the patients usually retain the power of 
standing, walking, masticating, and swallowing." 

I look on mental stupor as essentially the expression of an exhausted, 
low^ered, and devitalized brain. 

A typical case of this condition stands for hours where he is placed in 
the same attitude, when spoken to he takes no notice, he shows no active 
desires or aff"ections, he does not speak or move, or show any interest in 
anything. His expression of face is vacuous, his vaso-motor power 
is usually much below normal so that his extremities look blue and are 
cold, he does not obey the calls of nature, or take any notice of them at 
all. Loud sounds make no impression, pleasant or terrible sights that 
would in others produce motion and emotion fail to do so. A woman once 
committed suicide by hanging herself in a dormitory at Morningside in 
the presence of another woman in a condition of stupor, who took no 
notice whatever of this frightful sight. 

Looking at the condition of stupor from the point of view of the phy- 
siology of the brain, we sec that its })Ower of receiving impressions from 
without is in abeyance, and its higher reflex functions are suspended. 
The mental and motor irritation of a full bladder or loaded rectum is not 
felt by the higher brain centres ; and when through the action of the 
lower centres, evacuations take place, there is either no consciousness on 
the part of the higher centres, or, if there is, it does not result in the 
volition that prepares suitably for them, or in the vexation that would be 



218 STATES OF MENTAL STUPOR. 

felt in health, if they took place over the body. Even the ordinary skin 
and spinal reflexes are much diminished or abolished. The appetites for 
food and drink are paralyzed, or if felt are not followed by any exertion to 
satisfy them. 

A striking exception, and the only material exception to the passivity 
or suspension of brain function in stupor is regard to the reproductive 
instinct in a low morbid form. In the first place, most of the typical 
cases of stupor occur in the actively reproductive period of life. Most 
of them, in fact, are under thirty. Dr. Hack Tuke^ found that twenty- 
seven was the average age in twenty cases. In my experience all the 
very typical cases are nearer twenty than thirty. In by far the majority 
of the cases, the commencement of the disease had been connected with 
or accompanied by a sexual excita,tion in some form or other. Many of 
them had indulged in the habit of masturbation to a very morbid extent 
indeed, and had exhausted the brain energy thereby, had "stupefied" 
themselves, in fact, by this. Most of them indulged in this habit long 
after they had entered into a condition of mental stupor, doing it auto- 
matically rather than volitionally, and many of them have sexual 
delusions at the expiration of the attack. 

Many of these girls had been hysterical, and showed during their dis- 
ease marked hysterical symptoms. The aspect, expression of eyes, and 
behavior before the other sex, while consciousness existed, were markedly 
erotic, this being so in some of the cases, even after speech and all 
outward mental manifestations had ceased. Many of them have catalep- 
tic, trance, and hystero-epileptic symptoms, all these affections being most 
strongly, in my opinion, connected with the function of reproduction, its 
disorders, or its perversions. The direct connection of stupor in most 
cases with the reproductive and sexual functions has not been sufficiently 
considered hitherto. I look on those functions as the dominant vital 
activities from adolescence to thirty-five in many persons of the neurotic 
diathesis. If the inherent brain stability is hereditarily weak, with the 
inhibitory powers poorly developed, and if under those circumstances 
there is much intense sexual excitement or a constant sexual drain 
through- masturbation or sexual intercourse, stupor, in some form or 
degree, is, in my opinion, the natural expression of the exhaustion of the 
higher nerve force that follows. We shall see examples to prove this 
presently. 

When I thus bring out strongly the connection of stupor with the 
reproductive function, it must be remembered that I am referring par- 
ticularly to that form which is attended by unconsciousness, though this 
may have a distinctly melancholic stage or tinge throughout (mental 
depression too being a symptom of brain exhaustion) ; and it must be 
kept in mind that there are cases of stupor of the melancholic type 
resulting from other causes, such as mental or nervous shocks, frights, 
losses, or bodily diseases, which have no reproductive or sexual complica- 
tion at all. 

The voluntary motor system is found, on examination, to be in three 
conditions in different cases or in different stages of the same case, viz., 

1 International Medical Congress, 1881, Transactions^ vol. iii. p. 638. 



STATES OF MENTAL STUPOR. 219 

(1) quite passive, unresistive, and having no tendency to keep fixed posi- 
tions ; (2) cataleptic, with decided tendencies to keep fixed attitudes and 
positions, but with no resistance to external force used in changing the 
muscular positions; (3) resistive, showing a more or less strong resist- 
ance to external efforts to change the position. The first is commonly 
found in the anergic form of stupor, especially when it is caused by a 
previous acute attack by masturbation, general paralysis, or alcohol; the 
second, also, in some of the anergic reproductive cases; and the last in 
the melancholic form alone. 

Looked at from the purely mental point of view, conditions of stupor 
are divisible into three varieties, viz., the unconscious — the anergic — 
where consciousness and memory are gone; and the conscious — the 
melancholic — where they are both present, and where there is a delusion 
present, these facts being ascertained and tested afterwards by the 
patient's own account; and the half-conscious or confused, where there is 
some consciousness, but by no means a keen or a correct subjective 
realization of events, and where the recollection of them afterwards is 
confused or delusional. Some cases pass through all these conditions in 
different stages. Conditions of mental stupor have excited much interest, 
and have an extensive literature, especially in France, to which of course 
I have no time to refer. Mr. Hayes Newington, when assistant physi- 
cian at Morningside in 1874, studied them carefully, and wrote a capital 
description^ of them, with which I in the main agree; indeed, all must 
agree with him, for he sticks closely to clinical fact. He gave us the 
admirable word ^^ anergic'' to describe the passive, unconscious, non- 
depressed cases. This should take the place of the older term Acute 
Dementia, still commonly applied to such cases. It should certainly be 
discontinued, for it is confusing and incorrect. If you take a typical 
case of either the melancholic or the anergic, each undoubtedly cor- 
responds to his descriptions ; but an extended clinical experience has 
shown me that the same case may begin by being in the condition of 
melancholic and conscious stupor, and may end by being in the anergic 
and unconscious. Then I find that by far the greater number of the 
cases that were anergic during the greater part of their course had a short 
melancholic stage to begin with. As for stupor being a primary affec- 
tion I call to mind very few cases where it was entirely so. It scarcely 
ever begins as stupor. There is a stage of mental depression or of 
mania, very short, it may be, but still present. The stupor may have 
been the disease for all practical and clinical purposes, but still the 
initiatory stage of another condition was there. The cases which we 
shall see, or to which I shall refer, will illustrate those various points of 
causation and symptoms. 

The best clinical division of stupor would be, I think, into the following 
kinds; which, in the order of their frequency or importance, are: 
a. Melancholic stupor. 
h. Anergic stupor. 

c. Secondary stupor (transitory after acute mental disease). 

d. General paralytic stupor. 

e. Epileptic stupor. 

1 Journal of Mental Science, October, 1874. 



220 STATES OF MENTAL STUPOR. 

Melaxcholic Stupor is by far the most frequent and the most 
important form. It is the melancholia attonita, or the melancholie avec 
stupeur of the authors. As I have said, it is, either throughout its whole 
course, or at some part of it, the conscious and delusional form or the 
half-conscious looked at from the mental point of view, the resistive 
looked at from the volitional muscular aspect, and the non-paralytic 
looked at from the vaso-motor point of view. Some authors write as if 
there was always one overmastering delusion of a terrible kind, the 
patient fancying himself dead, or that he is too wicked to hold intercourse 
with his fellow-men, or that, if he speaks, he will be killed, which, as it 
were, fills the whole mental vision, and leaves no room for any other 
manifestation of mind, paralyzing speech and active volition of any kind. 
I do not think this a true view to take. There may or there may not be 
such a delusion, but by itself a delusion never causes stupor. There 
must be something more than this. There is always in addition a dis- 
tinct morbid condition of the brain affecting its reflex action, its trophic 
energy, its receptive power in all directions, and most especially its active 
ideo-motor functions. None of these things are the concomitants of 
merely delusional conditions. I look on the delusion as one symptom 
only, and not the cause of the melancholic stupor. Melancholic cases are 
sometimes suddenly impulsive at one period of the disease, and it is well 
to remember that during convalescence they may be suicidally impulsive. 
Gusts of motor energy seem suddenly to be evolved in the brain. I 
have seen epileptiform fits occur occasionally in such cases, but much 
more frequently a condition merely simulating epilepsy or apoplexy, the 
patient being conscious and having control over the muscular move- 
ments. Whenever you see a melancholic patient said to be "in a fit," 
always think of this condition. It is very common. In some instances 
this state occurs as the acme of an ordinary case of delusional or excited 
melancholia, being a short incident in the case. In other instances, 
though preceded by depression of mind, the stupor is the chief part of 
the disease. In some instances the stupor remains characteristically 
melancholic all through — being conscious, resistive, and unaccompanied 
by vaso-motor paralysis. In other instances it passes into anergic 
stupor — the patient being unconscious, unresistive, and with vaso-motor 
and trophic paresis. Some cases of melancholic stupor assume melan- 
cholic attitudes. Here is a young woman who lies flat on the ground, 
wdth her face on the floor, and she resists being placed on a chair. Here 
is a young man who is bent down till he almost crouches. Here is 
another who puts his fingers to his ears and keeps them there. The 
following are three cases of melancholic stupor, the first two (F. M. and 
F. N.) being patients of the ordinary type, and the third, F. 0., being 
a very extraordinary case in its severity, duration, and length of time he 
was artificially fed, and in its termination in recovery in these circum- 
stances : 

F. M., set. 21, a well-educated, bright, clever, and industrious youth 
of sanguine temperament. No nervous heredity admitted. Habits tem- 
perate and correct. The cause of the attack was over-study when he was 
rapidly developing in body, and had not attained manhood. His brain 
was exhausted by the body function, growth, development, want of sleep, 



STATES OF MENTAL STUPOR. 221 

and continuous mental effort. His first symptoms began eighteen months 
ago, and were mental depression, sleeplessness, and pain in the head. 
He got worse in mind and body, and soon became suicidal — attempting 
to take away his life. He became suspicious too, his aiFection for his 
relations diminishing, and he was fickle. He then got so much better 
through rest and change that he resumed his work and studies. When 
he relapsed, a few weeks before admission, he became again very suicidal 
— asking for poison, and wanting to drown himself. His motive for 
suicide was that people were going to kill him. On admission he was 
much depressed, though he could pick himself up and smile in a forced 
w^ay. He was very suspicious, imagining that he had done some great 
crime, and that he was to be tried and would be hanged. He was thin, 
his muscles flabby, his pulse sixty and weak, bowels constipated. Tem- 
perature — 97.2° in the morning, 96.4° at night. Weight, nine stone ten 
pounds. He was unsettled and restless at night as well as being sleepless.. 
His appetite was poor. He was evidently all the time looking for the means 
of suicide, so he was carefully attended night and day. He got more 
confused and more obstinate, until in a fortnight after his admission he 
was in a state of complete stupor ; his countenance wore a heavy semi- 
vacuous, semi-depressed expression ; he would not answer questions or 
take notice of anything ; was utterly careless of his dress and person, 
letting his motions pass where he stood. The skin had a warm clammy 
feel, except at the extremities, which were blue and cold. He had a few 
lucid intervals of a few minutes each, when he would as it were wake up 
and ask where he was. The treatment from the beginning consisted of 
his being compelled to take an enormous quantity of milk and eggs in 
liquid custards, flavored with nutmeg, and with half a glass of sherry in 
each. He took usually in the day twelve eggs and six pints of milk, 
and began to gain in weight after the first fortnight. He had quinine 
and strychnine in moderate doses, and cod-liver oil emulsion, containing 
hypophosphite of lime and pepsine. He was walked in the open air a 
great deal. His skin was well rubbed with rough towels night and 
morning, and occasionally he had the continued current up to fifteen 
cells. He steadily gained in weight. After three months' treatment he 
began to speak, and wrote the following letter to his mother: ''My 
mother, please let me go home. I don't know where I am. I feel very 
ill. Would you let me go home." In a few days he wrote to her to 
send him some money to pay for his maintenance here, saying that he 
thought about ^3000 would do, that he was a nuisance to those round 
him, and asking what great crime he had committed, and requesting that 
he might be punished adequately. In another month the confusion of 
mind was passing away ; in a month from that he was practically well in 
reasoning power, in feeling, memory, and in bodily health, and was over 
eleven stone in weight. He was bright, intelligent, lively, and a groat 
favorite. He said he remembered in a confused way the events that 
occurred during his period of stupor, that he had the delusion all the 
time he had committed a crime, and was to be punished, and could not 
pay for the food given to him. When discharged, six months after 
admission, I never Avas more satisfied in any case that a completo recovery 



222 STATES OF MENTAL STUPOR, 

had been made. I always like to see a patient get fat on recovery from 
any form of insanity. 

This was a very typical case of melancholic stupor, showing well how 
the stupor was the acme of the brain condition, Avhich showed itself first 
as melancholia, how there was a melancholic tinge through the stupor, 
and a distinct melancholic delusion. But I conceive it would be a mis- 
take to describe the stupor as being caused by a profound delusion. As 
a matter of fact, in this, as in all such cases, the intensity of realization 
of the delusion, and the capacity to feel keenly, were blunted by the con- 
dition of stupor. The stupor I look on as a brain condition distinct 
altogether from that of acutely felt depression in melancholia, in w^hich 
delusions are vivid, and the misery profound. We find that delusions 
alone never cause stupor, whatever their character. They may cause 
prolonged taciturnity for years, but this is totally difierent from stupor. 
The condition of the mental portion of the convolutions in stupor is 
analogous to the stupidity of a nervous child when terrified or bullied. 
I do not see any but a superficial analogy between stupor of any kind 
and hypnotism. 

The following was a case of melancholic stupor of short duration, and 
with a complete recovery : 

F. N., set. 35. Temperament melancholic. Habits intemperate ; a 
prostitute. Heredity — mother intemperate, and subject to periodic 
attacks of melancholia. Her illness began by melancholic depression 
and delusions, but she soon became excited, noisy, and tried to commit 
suicide. She had no great overmastering melancholic delusion to account 
for the stupor into which she soon passed after admission, which, was 
complete Avith all the characters of melancholic stupor ; muscularly 
resistive, no cataleptic tendency, refusal of food, and expression of face 
depressed. She would not walk or move, and had to be kept in bed. 
She remained in that state for about six weeks. It was evidently the 
acme of the attack of melancholia, and she shortly got better and made 
a good recovery in six months. She now says that the period of stupor 
was a blank to her, and she remembers nothing that took place then. 

The following was a case of prolonged melancholic delusional stupor, 
lasting three years, simulating "acute dementia," and requiring artificial 
feeding all that time, with final recovery. 

F. 0., set. 31. Admitted 26th January, 1876. Disposition retiring. 
Strumous diathesis. Habits unsocial, and almost too industrious and 
sedentary. Excessive masturbation. Father intemperate ; mother died 
of consumption. Had one slight attack of mental disease (melancholia) 
three years ago, from which he quite recovered in a few months. First 
symptoms of mental disease were slight depression and foolish fancies. 
Along with these there were sleeplessness, pains in head, loss of nutrition, 
and great coldness of extremities. Sometimes he could not be kept warm 
by any means used. Was not dirty, destructive, or obscene, nor violent. 
Those symptoms showed themselves fifteen months ago. As he got 
worse, he opened a vein, and lost some blood, and on several other 
occasions he seemed to have tried to choke himself with a scarf He 
was at times noisy and incoherent, and quite sleepless. He had changing 
delusions, e. g.^ that his brain was compressed by an evil spirit. 



STATES OF MENTAL STUPOR. 223 

On admission he was depressed and hypochondriacal, fancying that he 
was dangerously ill, that he had been a great sinner and very licentious, 
that he suffered shame more than all mankind, and that his body had 
been tampered with when he had attempted suicide. Along with the 
depression there were much mental enfeeblement, facility, childishness, 
and impairment of memory, with rambling and incoherence. He had 
delusions about his sexual organs. He was anaemic, flabby, thin, and we 
thought that there was slight comparative dulness at apex of right lung, 
with rough breathing sounds. Temperature, 98.4°. Height, five feet 
six and a half inches. Weight, eight stone thirteen pounds. 

He remained very much in this mildly melancholic condition for three 
months. He constantly wanted quack medicines, had a poor appetite, and 
used to twist and wriggle his body about in obedience to delusions. He 
then had an attack of deeper depression, with more confirmed delusions, 
intense insane obstinacy, impulsive violence, shouting at times and twist- 
ing his body about, as if there were beasts crawling on him. After this 
he refused food entirely in May, and was fed with the stomach-pump on 
May 7, 1876, resisting strongly. He took his food on the 17th, but 
again needed to be fed on the 18th, and for several weeks afterwards. 
Then for several months he took his food himself, his mental condition 
otherwise remaining much as beforp, and his delusions being very pro- 
nounced. But in May, 1877, he again began to refuse food, and from 
that time till April 80, 1880 — a period of over two years and eleven 
months — he took no food, and required to be fed twice a day with the 
stomach-pump. 

But this was not the most extraordinary part of his case. In the 
course of a month after his being fed, he had got into a condition of 
absolute stupor, lying motionless, insensible to pain, unable to stand, his 
urine and feces dribbling away, his circulation feeble, offering no resist- 
ance to anything done to him, and taking no notice iipparently of any- 
thing. Nothing could rouse him, nothing could stir him, nothing could 
excite any mental or bodily reply or response, except that he shut his 
eyes tightly when the eyeballs were touched, and there was slight motion 
of the legs when the soles of his feet were tickled. But this last reflex 
power disappeared in October, 1878. Much difiiculty was experienced in 
keeping him warm, but an old and most affectionate maiden aunt, who 
came to see him almost daily, contrived the most wonderful woollen foot 
coverings and body rugs. He was dressed in the morning, carried down 
to a sofa, and his penis inserted into an India-rubber bottle. There he 
lay all day, never moving, never resisting anything done to him. He 
seemed the most complete case of "acute dementia" or anergic stupor I 
ever saw, except for two things : these Avere, a certain expression in his 
face, which was never so absolutely blank as it is in that condition, and 
his not being able to stand or move at all, which seldom occurs. There 
was none of the resistance or muscular rigidity of melancholic stupor. 

As regards treatment, he was fed in the morning with a liquid moss, 
consisting of a pound of beef done to a liquid form in a large mortar with 
potatoes and vegetables siuiilarly pounded down, the whole being made 
liquid enough to pass readily through a stomach-pump tube with beef-tea 
and a quarter of a pound of sugar. In the evening he had a custard with 



224 STATES OF MEKTAL STUPOR. 



I 



three eggs and a quarter of a pound of sugar. His bowels kept regular. 
He had at various times quinine, strychnine, phosphorus, ergot, cod-liver 
oil, the hypophosphite of lime, iron, and the continued current up to 
twenty cells of a Hawksley's battery, used once a day for months together, 
through his brain and spinal cord. No good seemed to be done, yet he 
was a case about whom we never quite lost hope. His nutrition kept fair, 
and he did not lose weight. 

At last, in June, 1879, he was observed by his attendant to turn over 
on the sofa. Then reflex action on tickling of the soles was observed, 
and his countenance began to acquire more expression. The continued 
current was being used at this time, but I am very doubtful if it had any- 
thing to do with his improvement. In February, 1880, his glottis became 
more sensitive, so that the passage of the tube caused coughing, and he 
raised himself up after feeding once. One day he seized the tube and 
remained rigid and cataleptic for a few minutes. On April 30, 1880, he 
spoke for the first time, and at feeding time said he was tired of custards, 
and wanted some tea, took a moderate tea and supper, and a good break- 
fast. He had never lost weight during all the time of his artificial feed- 
ing. He took no food on May 1st, but on May 2d asked Dr. Clark, 
who was about to feed him, if it was the custom to keep sane men in the 
asylum, and on being told that it was not much like a sane man to refuse 
food, he replied, "Then if I take my food will that prove my sanity?" 
"Yes." "Then give it me at once." He took it there and then, and 
never missed a meal afterwards. He was weak and his appetite was 
feeble, but he soon began to walk, then to go out, and he got stronger, 
and heavier by nearly a stone than he was on admission. When asked 
about his stupor, he always gave some sexual reason such as that it was 
" gonorrhoea " or " emissions " that had been the cause of it. He asserted 
that he had been conscious all the time, and made some statements which 
proved that there had been some consciousness, reasoning power, and 
memory. He described how a sphygmograph was used on his radial 
artery, he told the names of assistant physicians who had been in charge 
of him during his stupor, and he "asked pardon for my conduct." His 
memory was not quite clear however ; he could not tell much about what 
happened, nor the year he entered the asylum. His memory of events 
before his illness was good, and he showed much curiosity as to what had 
been going on in the religious world. He was hypochondriacal, notional, 
and somewhat weak-minded, and was discharged relieved on June 21, 
1880. He has improved still further at home, his old maiden aunt 
thinking him as well as ever he was in his life, and considering him a 
most intelligent and exemplary youth. She takes almost the entire credit 
of his resurrection, a distinction which I am much inclined to award to 
her, for she kept him warm, she kept up the interest of every one in his 
case, and she never despaired of his recovery. 

This was essentially a case of melancholic stupor (melancholia attonita, 
pyschocoma, melancholic avec stupeur), with many of the features of 
"anergic stupor." In fact, after the symptoms attained their greatest 
intensity, when there was no apparent consciousness, no attention, no 
muscular resistance, no voluntary motion, and no spinal reflex function, 
when the body temperature was very low, the capillary circulation in the 



STATES OF MENTAL STUPOR. 225 

extremities was very weak, the urine and feces passing involuntarily and 
at all times, I considered the case as one of anergic stupor (acute de- 
mentia) that had arisen at first out of a melancholic condition, and used 
to speak of it as such, a fact of which the patient reminded me after his 
recovery. I certainly did not think there was consciousness, or attention, 
or memory really present, as the patient's recollections afterwards proved 
them to have been to some extent. In old times the case would have 
been called one of trance, and there were many of the features of what 
is now described in the books by that name. I think it probable that 
most cases of trance, if examined by an alienist, would be placed under 
melancholic or anergic stupor. It will be noted how well the digestive 
and trophic functions of the body were performed when there was no 
voluntary muscular action whatever. The great length of time during 
which the symptoms lasted, and the final recovery, so far as the stupor 
was concerned, are very marked features of the case, if they are not 
unprecedented. 

The following was a striking case of stupor (melancholic) following a 
mental shock: 

F. T., aet. 55, of a melancholic temperament, and steady and indus- 
trious habits, through which he had made and saved X6000. There was 
no known neurotic heredity. He was a shareholder in the City of Glasgow 
Bank, and the failure of that ill-fated concern, and the loss of all his 
money, seemed to "take the spirit out of him" completely. He became 
sleepless, nervous, and much depressed. He lost weight from fourteen 
stone to ten stone four pounds. He first spoke constantly about his being 
victimized and cheated, and then expressed delusions that he was in debt, 
and that he must go to the police office and give himself up. His delu- 
sions by and by referred to his body (no doubt his organic sensations, as 
he got thin, weak, dyspeptic, and costive, were those of discomfort), saying 
that his inside was burnt up. On his admission to the asylum, six months 
after the beginning of his disease, he was with difficulty got to speak, to 
answer questions, or to take food ; and he slept badly. He would appear 
as if he was to speak or answer a question, but the volitional power ta 
articulate seemed to fail him, and he would say nothing. His next 
delusion was natural enough, the wish being father to the thought. He 
fancied he was dead, and he would say ''I am dead; put me in my 
grave." Then for two months his stupor was complete, with no outward 
expression of mentalization at all. But the expression of face was 
melancholic as well as stupid, and there was muscular resistance. He- 
lay in bed. All this time he was getting weaker. No tonics excited his 
appetite, no stimulant — and he got brandy in large quantities — roused 
him, and his food did not nourish him. The news of his favorite 
daughter's death did not affect him. I have no doubt he had the delu- 
sion he was dead. He got thinner and weaker, and gangrene of his heel 
appeared, then hypostatic pneumonia, and lastly gangrene of the luno-s, 
of which he died eight months after admission. In the last month of his 
life, and especially when his temperature rose to 102.5° from the lung 
disease, lie would answer questions at times, and once or twice spoke 
sensibly, asking what sort of a, night he had had, but generally he wanted 
to be put in his grave and ''buried." 

15 



226 STATES OF MENTAL STUPOR. 

At the post-mortem examination we found considerable atrophy of the 
convolutions, and congestion of the brain substance. 

No dramatist ever drew a more vivid picture of adversity overwhelm- 
ing a man, striking him dumb, crushing the whole vitality of mind and 
body out of him, and soon killing him outright. 

This case brings out strikingly the lowered and devitalized condition 
of the brain, which I look on as, after all, the proximate cause of mental 
stupor. 

ANERGIC Stupor (Acute Demextia). — This may be a primary dis- 
ease commencing without any melancholic or maniacal stage, though I 
have never met with a case in which I could not discover at least a trace 
of these conditions at the beginning of the attack. Its symptoms are 
complete unconsciousness, and of course no after memory of events that 
occurred during its persistence ; no delusions ; no muscular resistance ; 
but in some cases a static or cataleptic muscular condition ; a loss of facial 
expression ; a marked vaso-motor paresis, so that the extremities are blue 
and cold ; a lowering of the trophic energy, so that sores are apt to form 
and even gangrene may occur: the reflex functions of the cord are 
markedly diminished, and the higher reflex functions of the brain almost 
in abeyance. 

The following case, F. P., was one of anergic stupor, occurring in a 
girl of eighteen, who had had two slight attacks of melancholia on pre- 
vious occasions. One grandfather had been melancholic with delusions, 
but not in an asylum ; father had several epileptic attacks, and had been 
very "excitable" after each; sister became "dazed" after, and in con- 
sequence of, mother's death and died of phthisis in four months ; and a 
brother was eccentric and foolish. Masturbation suspected. The attack 
began by a short maniacal stage, with much incoherence, " laughing in a 
childish way." This passed into a condition of stupor in two months, 
during the continuance of which she never spoke, and stood in one posi- 
tion, or sat where she was placed. She swallowed liquid food when put 
into her mouth, but showed no desire for anything or interest in anything. 
Loud noises near her did not startle her. She did not obey the calls of 
nature. She was cold, her feet blue and swollen, her pulse weak and 
quick, and the reflex function of spinal cord abolished. There was no 
muscular resistance and no catalepsy. After about a month she seemed, 
under the use of stimulants, nerve tonics, and blisters to the occiput, to 
improve somewhat, but she soon fell back again, and remained ill for 
over a year. Menstruation, which had been absent for the first six 
months, returned, and she seemed to be none the better for it. As she 
began to improve she got a little obstinate and even violent, and her 
brain was for a time in the repeating state one sees sometimes in certain 
cases of mental disease. When asked a question she would repeat the 
words said, or part of them, like a parrot, as the reply. After she 
began to improve she rapidly got well, having been previously fattened 
with milk diet, and she has remained quite well now for seven years. 

This was a case with cataleptic symptoms. 

F. Q., set. 27, admitted 2d April, 1881. Disposition bright and 
cheerful. Habits steady and industrious. First attack. No hereditary 
predisposition. Cause, anxiety in regard to an operation for removal of 



STATES OF MENTAL STUPOR. 227 

mammary tumor which she had to undergo. Duration about five weeks. 
Became gradually depressed, lost appetite, fell off in flesh, slept badly. 
Ultimately became quite stupid, was unfit for her work, took no interest 
in her children, would stand in one position for an hour or two continu- 
ously, and was very restless at night. 

On admission she was in a state of stupor, paying no attention to 
questions addressed to her or to anything occurring near her, would not 
utter a word, stood in a listless and stupid attitude, obeyed no orders, 
refused food, did not attend to the calls of nature. She was in very 
poor condition and weak general health. She was unresistive, cold, and 
her extremities blue, and her face expressed vacancy, not melancholy. 

April 3(i. — Slept well for some hours, but was restless in the morning. 
Remains in a state of stupor, and will not speak a single word. There 
is a distinct degree of catalepsy. Has taken plenty of food. To have 
custards, plenty of extra milk, porter, and cod-liver oil emulsion, and 
friction to skin, with extra warm clothing. 

April 7th.- — Takes her food readily when fed with it. Still very 
stupid. Never utters a single word. Will not employ herself in any 
way. Wanders slowly and aimlessly about the gallery when set in mo- 
tion. When allowed to do so will sit or stand any length of time. 

April 10th. — General health rather improved. Yesterday she spoke 
a few sentences to the attendants. 

April 15th. — Expression of face more intelligent. Is obstinately 
taciturn. Sleeps well. 

April SOth. — Bodily health improving. Mentally little change. 

Ma^ Slst. — Has been worse since last note ; stupor more pronounced ; 
cannot be got to speak, or to work, or to attend to herself; wet and dirty 
in her habits. 

JVov. 1st. — Stupor extreme. Sits constantly in one j^osition, with 
head bowed down, and saliva running from her mouth. Eyelids are 
oedematous, pulse almost imperceptible, extremities cold. Ordered 
quiniae sulph. gr. iv., tinct. digitalis % xv., three times daily. 

JVov. 27th. — Has been confined to bed for some days lately, owing to 
the extreme general weakness. Mentally there is some improvement, as 
she brightens up slightly at times, but there is generally profound stupor. 

March, 1882. — There is still pronounced stupor, but its character is 
considerably changed ; the mental faculties seem blunted or dead ; she is 
utterly careless and apathetic ; she is slovenly and dirty, requiring to be 
washed, dressed, and attended to in every respect ; she never volunteers 
a remark, and indeed never utters a single expression, except when being- 
bathed or dressed, when she sometimes gives vent to expressions of dis- 
approbation and disgust. Her expression of fiice has also changed of 
late. Her general look is one of utter stupidity and degradation, the 
features being coarse and blurred, the saliva dribbling from the mouth ; 
but frequently, without apparent external cause, the face assumes various 
exaggerated expressions of disgust, amusement, and eroticism, while at 
times she has muffled outbursts of chuckling laugliter. She takes plenty 
of food, and is in better health and condition. ^luscularly she is cata- 
leptic to a marked degree. 



228 STATES OF MENTAL STUPOR. 

In the next twelve months she improved in many respects, but she 
then died of diarrhoea. 

The folloAving is a case of anergic stupor, beginning with slight melan- 
cholic symptoms, and caused by excessive drinking : 

F. R., get. 40, a person of a naturally bad and untruthful disposition, 
whose exact heredity is unknown. She is the daughter of a Hindustani 
mother, her father having been English. Her habits were always indo- 
lent, but of late they have been very drunken, fickle, and degraded. 
Her present attack began by melancholic fears that persons were going 
to kill her, restlessness, incoherence, and screaming at night. She still 
drank, and has become more and more confused and stupid. On admis- 
sion she was in a condition of stupor, with a slight melancholic tinge. 
This soon passed off, and her stupor became complete and anergic in 
character, with poor circulation, j)ulse weak, extremities cold ; urine and 
feces passed as she lay on a water bed. 

Nothing would rouse her to speak or take any notice of anything. 
For about a year this condition continued, and then she gradually came 
out of it in a partially demented condition, with uncleanly habits, erotic 
speech, masturbation, talking and laughing to herself, delusions of iden- 
tity, inability to fix her attention on anything, and a morbid contentment 
with her position in the asylum. Thus she has remained for four years 
now, and thus she will probably remain as long as she lives. 

The following is a complicated case of stupor, catalepsy with epilepti- 
form convulsions ; temporary partial recovery, dementia : 

F. S., aet. IT, admitted to Royal Edinburgh Asylum, 2d May, 1874. 
Disposition quiet and dull ; habits steady ; family history not ascertained ; 
assigned cause a severe blow on the back of the head three years before 
admission, since which he has been duller and more stupid. The injury 
seems to have been chiefly spinal. After it he gradually lost complete 
control over the movements of his head ("it came forward"), then he 
ceased to be able to stretch his arms forwards and back, but he still could 
write. Was sick, and sometimes vomited. Could not walk far or run 
at all without being very tired. Had pain in his head. About three 
weeks ago showed mental symptoms, viz., religious anxiety, delusions 
that his food and medicine were poisoned, shouting, violence, and dirty 
habits. It appears that an epileptic fit immediately preceded those symp- 
toms. Took another fit sixteen days before admission, springing right 
up from his bed. Convulsions lasted three-quarters of an hour. During 
the fit the lip and tongue were bitten. He was then for five hours in 
" a trance." His head had been shaved and blistered. Had six or seven 
fits subsequent to this, and before admission. 

On admission he was in a state of stupor, with no mentalization ap- 
parent, insensible to pain, and spinal reflex action abolished. Pulse 130, 
weak ; temperature 97.8°, was very weak ; urine and feces passed in bed. 

He remained in this stupor, but sometimes cried and moaned, and took 
many epileptiform fits for the first ten days. He then showed the true 
cataleptic symptoms, his body assuming any position it was placed in for 
any length of time. He took no notice of anything, and would not 
answer questions. One night the attendant got him up, put the chamber- 
pot in his hands under his penis, went away, and forgot all about it, and 



STATES OF MENTAL STUPOR. 229 

he was found in the same position in the middle of the night by the night 
attendant. He remained cataleptic and unconscious for eight days, when 
he had a feverish attack with diarrhoea, temperature being 103°. While 
this lasted, he could be roused to answer questions in monosyllables, and 
appeared to be more conscious and intelligent. After the fever subsided 
he again became completely cataleptic. There collected and ran out of 
his mouth a fetid greenish fluid somewhat purulent in character. Some- 
times he had to be fed with the stomach-pump. The food always had to 
be made liquid. During all the time, up till August 10th, he had mus- 
cular twitchings of the extremities, and occasionally a regular epileptic 
fit. Pulse then 60, weak and irregular; temperature 98.9°. 

During September he began to move slowly by volition in a snail-like 
way, without speech or expression in his face. When up, and told 
sharply to get into bed, he would move slowly and manage to get there 
in half an hour or so. Bowels very costive. When much roused, on 
September 17th, he got up and walked along the corridor. There were 
no fits after the 18th of September. He steadily improved after this, 
still being slow and stupid, affectively religious, going to church, and 
saying very long prayers before going to bed. In October he was able 
to dress, undress, go out to do a little garden work, but stolid, slightly 
enfeebled in mind, reserved, wanting in curiosity and interest, and as if 
he had some latent morbid fancies. 

On November 8, 1875, he was discharged as "recovered," being co- 
herent and intelligent, but there was present some of the general listless 
mental state referred to. 

He did very well at home for a time, but a process of gradual mental 
enfeeblement seems to have come on, with irascibility and sometimes 
violence, so that, on 4th of June, 1878, he was readmitted to the asylum 
in a state of ordinary sequential dementia. He still remains there. He 
has never had any recurrence of the epileptiform fits. 

There are two additional facts which one may assume, though they do 
not appear in this record. The first is that there must have been a 
strong heredity to insanity. The second is that the lad practised mas- 
turbation to excess. 

He says he has no recollection of Avhat occurred during his period of 
stupor. That I believe. I look on such a case as being partly caused 
by adolescence, complicated by masturbation and traumatism, all of which 
were concerned in the causation of the epileptic attacks and the condition 
of stupor. 

Secondary Stupor. — All acute forms of mental disease are liable to 
be followed, after the acute symptoms have passed off, by a condition of 
mental torpor and a kind of mental enfeeblement. But this differs es- 
sentially from the true secondary dementia. There is in it to a large 
extent the mental characters which I have described as being those of 
stupor, and above all it is curable. The patients are inattentive, con- 
fused, lethargic, and torpid. The brain reflexes are dulled. The ener- 
gizing of the convolutions is slow and confused. All the higher reason- 
ing and affective powers are in abeyance for the time being. It is a time 
of exceeding importance for treatment, which should be supporting, tonic. 



230 STATES OF MENTAL STUPOK. 

nutritive, and not exciting ; though nerve stimulants and counter-irrita- 
tion to the head are often of service. 

General Paralytic and Epileptic Stupor. — The condition of 
stupor of the anergic kind is often an incident in those two diseases, most 
frequently following attacks of convulsions or congestive attacks, but 
sometimes coming on of itself without any reference to such motor symp- 
toms. Wherever there has been prolonged stupor in general paralysis, 
we find much brain atrophy after death. 

Causatiox. — The causes of stupor are the following: 

1. Sexual. The chief of these is the habit of masturbation. I have 
met with it also as a post-connubial condition, or from excessive sexual 
intercourse in both sexes in adolescents. In some cases it seemed as if 
the mental and emotional exaltation had acted as strongly as the physical 
exhaustion. F. P., and F. S. were examples. 

2. Mental and moral shocks and over-work during adolescence. 

3. The brain exhaustion caused by acute mental diseases, more especi- 
ally acute mania. 

4. Stupor often occurs as an incident or stage in other mental diseases, 
notably, as we have seen, in general paralysis and epilepsy. 

5. An alcoholic stupor may be caused by excessive drinking, and is 
thus one form of alcoholic insanity. Such a condition is usually transi- 
tory, but not always. 

6. Stupor is frequently one of the stages of alternating insanity fol- 
lowing the exalted condition. It is more apt to occur in those where the 
exalted period is acutely maniacal. This stupor is usually the melan- 
cholic form. The older the patient the more apt is the stage of reaction 
after exaltation to be one of stupor. I have now under my care an old 
gentleman of eighty-four, who, when his periods of exaltation are unusually 
long, will afterwards become torpid, never speak or take any notice of 
anything, will not even stand, but must be kept in bed, will scarcely 
swallow, and this will sometimes continue for four or five weeks. When 
younger, he never had such attacks. He has labored under irregularly 
alternating insanity for thirty years. 

7. Senility. In the extreme form of senile insanity, the mental facul- 
ties disappear so entirely as to constitute them cases of stupor. 

Some of these causes may, of course, coexist. The sexual and alco- 
holic are very apt to do so. 

Prognosis in Stupor. — In its typical form, in young persons of both 
sexes, the anergic form (acute dementia) is a very curable form of mental 
disease. The melancholic form is not so curable, but about fifty per cent, 
of the cases recover. 

Treatment of Stupor. — All forms need much the same treatment, 
but in the anergic cases it needs to be supporting and stimulating, and 
in the melancholic more supporting at first, and stimulating afterwards. 
Quinine, iron, strychnine pushed to large doses, ergot, warmth, the con- 
tinued current, exercise, friction, alcoholic stimulants, rousing moral 
treatment, occupation, distraction of mind are the general indications. 
In the relation of the clinical histories of the cases described the treat- 
ment has been sufficiently spoken of. 



LECTURE IX. 

STATES OF DEFECTIVE INHIBITION {PSYCHO-KINESIA ; HYPER- 
KINESIA; INHIBITORY INSANITY; IMPULSIVE INSANITY; INSANE 
IMPULSE; VOLITIONAL INSANITY; UNCONTROLLABLE IMPULSE ; 
INSANITY WITHOUT DELUSIONS , EXALTATION, DEPRESSION, 
OR ENFEEBLEMENT ; AFFECTIVE INSANITY). 

THE INSANE DIATHESIS. 

The want of the power of self-control is so very common a thing 
amongst mankind, that to some extent, and in respect to some matters, it 
may be regarded as the normal condition of our species. A perfect 
capacity of self-control in all directions and at all times is rather the ideal 
state at which we aim than the real condition of any of us. The men 
who have attained this state of inhibitory perfection have been few and 
far between, and even in regard to them it may be said that they too 
would have lost their self-control if they had been exposed to sufficient 
temptation or irritation. But while a perfect mental inhibition may not 
be attainable, there is a certain amount of this power in all directions, 
and an absolute power in some directions that is expected of all sane 
persons. All sane men must control to some extent their animal desires, 
and they must control absolutely any desires they may have towards 
homicide. The law assumes, as the basis of all its enactments, that all 
men have the inherent power to do certain things and avoid other things 
that would be inconsistent with the well-being of society, or the safety or 
comfort of their fellow-men. If a man is born of criminal parents, and 
has been taught to prey on his fellows, and look on them as having no 
rights that he is bound to respect, if from no fault of his own his brain 
is weak, and no sense of right and wrong has been implanted in him at 
all, yet in spite of all this he is held as fully responsible by the law as 
the strongest, best taught, and most favorably circumstanced man in the 
country; and this is at present unavoidable, however unscientific it is 
from the physiological and psychological aspect of brain and mind func- 
tion. Laws are, after all, largely the reflexes of the laws of nature. If 
a man has not been taught that an excessive use of alcohol damages or 
kills, and he drinks it to excess, he suffers just as much as the man who 
knows its bad effects, and deliberately poisons himself with it. But to 
this assumed power of mental control in all men the law makes certain 
exceptions. The first of these is in regard to children, and the second is 
in regard to persons whose mental power has been affected by disease or 
want of brain development. 

The subject of mental inhibitory power should first be studied by us 
medical men from the point of view of its gradual ilovolopmont in chil- 
dren. Take a child of six months, and there is absolute] v no such brain 



232 STATES OF DEFECTIVE INHIBITION. 

power existent as mental inhibition ; no desire or tendency is stopped or 
controlled by a mental act. At a year old the rudiments of the great 
faculty of self-control are clearly apparent in most children. They will 
resist the desire to seize the gas flame, they will not upset the milk jug, 
they will obey orders to sit still when they want to run about, all through 
a higher mental inhibition. But the power of control is just as gradual a 
development as the motions of the hands. There is no day or year in 
a child's life after which killing its little brother is murder, and before 
which it was no crime at all. The law admits and provides in a rough 
way for this physiological fact as to self-control. We physicians see that 
this faculty is developed at different ages in different cases. We are 
bound to give credence to all physiological facts and laws, and it is as 
much a fact that different brains have different degrees of controlling 
power after their full development, as it is that they attain their power of 
control at different ages. As we watch children grow up, we see that 
some have the sense of right and wrong, the conscience, developed much 
sooner and much stronger than others, just as some have their eye-teeth 
much sooner than others ; and, looking at adults, we see that some never 
have much of this sense developed at all. This is notoriously the case 
in those whose ancestors for several generations have been criminals, 
insane, or drunkards. Then, again, in other persons the sense of right 
and wrong is painfully keen from early childhood, and the desire to follow 
the one and avoid the other earnestly striven after from the first. In 
some, therefore, conscience is anaesthetic, in others hyper^sthetic, just as 
sensation may be. Notoriously it is a bad thing to force any sense or 
mental faculty into too great activity till its brain substratum is sufficiently 
developed. I have known many children whose anxious parents had 
made them morally hypersesthetic at early ages through an ethical forcing- 
house treatment. I knew one little boy of four, who, by dint of con- 
stant effort on the part of his mother, was so sensitive as to right and 
wrong that he never ate an apple without first considering the ethics of 
the questions as to whether he should eat it or not; who would suffer 
acute misery, cry most bitterly, and lose some of his sleep at night if he 
had shouted too loud at play, or taken more than his share of the cake, 
he having been taught that these things were "wrong" and "displeasing 
to God." But the usual anaesthesia that follows too keen feeling succeeded 
to the precocious moral intensity in this child, for at ten he was the greatest 
imp I ever saw, and could not be made to see that smashing his mother's 
watch, or throwing a cat out of the window, or taking what was not his 
own, were wrong at all. We know that some of the children of many 
generations of thieves take to stealing as a young wild duck among tame 
ones takes to hiding in holes, and that the children of savage races can- 
not be taught at once our ethical feelings. It seems to take many gen- 
erations to redevelop an atrophied conscience. Professor Benedick, of 
Vienna, showed, at the International Medical Congress of 1881, in 
London, a number of brains of habitual criminals which he affirmed had 
their convolutions arranged in a certain simple form peculiar to the 
criminal classes, so that on seeing such a brain he could tell the ethical 
tendencies of the person to whom it belonged, just as you can tell a dog 
to be a bull-dog by his jaws. There is no doubt that an organic lawless- 



STATES OF DEFECTIVE INHIBITION. 233 

ness is transmitted hereditarily. Among the many transmitted morbid 
peculiarities in the children of neurotic and insane parents this is often 
one. Either a too morbid intensity of desire, or a morbid weakness of 
control, renders such children prone to early morbid immoralities. 

In the delirium of fevers and the ravings of the acuter forms of in- 
sanity, no form of self-control is expected. The law, from the earliest 
times, entirely exempted persons suffering from such conditions from 
responsibility for acts done under their influence. A study of the dif- 
ferent varieties of insanity shows us that the power of self-control differs 
enormously in the various forms, and in different individuals laboring 
under the same form, while there is no line of demarcation between the 
state in which a man has "perfect self-control " (to use an expression that 
cannot be literally true in any case) and that in which he has none at 
all. Self-control, in short, like all physiological qualities and all mental 
faculties, exists in every possible degree of strength. Sufficient power 
of self-control should be the essence and legal test of sanity, if we had 
any means of estimating it accurately. The accurate clinical study of 
mind in relation to its ordinary physiological accompaniments, in health 
and disease, will, I believe, help us in time to make such an estimate in 
any particular case far more accurately than w^e are now able to do. 
The practising physician, from his daily acquaintance with the physio- 
logical facts of nature, instinctively makes allowances for lack of self- 
control in his patients when they are ill, apart from technical insanity. 
He knows that the thing called "irritability" merely means lack of full 
vital power, that the "impulses" of the hysterical girl are simply mor- 
bidly transformed modes of energy temporarily bursting the bounds of the 
patient's wdll, just as fits of weeping are often involuntary and uncon- 
trollable. But the lawyer, and the medical man, who, as a medico-legal 
witness or adviser, has to consider the social and legal aspect and effect 
of his opinions, are still chary of admitting mere loss of control or morbid 
impulse as an excuse for crime. They both like to have other evidence 
of disorder of the mental function, in the shape of insane delusion or 
incoherence of speech, before they are willing to put forward the plea of 
diseased want of self-control in mitigation of legal punishment. Another 
element than medical facts comes in then, viz., the practical effect of their 
opinions on society. In a community of perfectly law-abiding people a 
murder would naturally be attributed to disease, and no objection would 
be taken by any one to that view of it. But with the world as it exists, 
it is different. 

Before we can give any opinion as to the responsibility or irresponsi- 
bility of any case in a court of law, we should see as many cases as we 
can where want of controlling power or impulsive tendencies constitute 
the disease or the chief part of it. Such cases exist, though they are not, 
in a pure form, very numerous. As one stage in cases of insanity they 
are frequent. Half the suicidal melancholies at the beginning dread the 
moment when their self-control will be lost. Many of the maniacal cases 
show at an early stage only loss of self-control, before motor excitement 
or incoherence comes on. If one has seen many persons in this state 
about Avhom there could be no doubt as to their disease, and if one lias 
systematically studied the loss of self-control or morbid impulse as a 



234 STATES OF DEFECTIVE INHIBITION. 

mental symptom in the various forms it is found to assume, such experi- 
ence and study bring much confidence to us in giving private medical 
advice about this matter, or in giving evidence in the witness-box in 
regard to one of the most responsible and difficult questions about which 
a medical man has to come to a decision. 

Consider first the variety of simple motor impulses or acts that are 
physiologically uncontrollable, or partly so, such as coughing, vomit- 
ing, etc. Next, look at a more complicated act, that will be recognized 
by any competent physiologist to be automatic and beyond the control of 
any ordinary inhibitory power, e. g.^ irritate and tease a young child of 
one or two years sufficiently, and it will strike out at you ; suddenly strike 
at a man, and he will either perform an act of defence or offence, or both, 
quite automatically, and without power of controlling himself. Place a 
bright tempting toy before a child of a year and it will be instantly 
appropriated. Place cold water suddenly before a sane man dying of 
thirst, and he will take and drink it without power of doing otherwise. 
Exhaustion of nervous energy always lessens the inhibitory power. AVho 
is not conscious of this? ''Irritability" is one manifestation of this. 
Many persons have so small a stock of reserve brain power — that most 
valuable of all brain qualities — that it is soon used up, and you see at 
once that they lose their power of self-control very soon. They are 
angels or demons, just as they are fresh or tired. That surplus store of 
energy or resistive force which provides in persons normally constituted 
that moderate excesses in all directions shall do no great harm, so long 
as they are not too often repeated, not being present in those people, 
over-work, over-drinking, or small debauches, leave them at the mercy of 
their morbid impulses without power of resistance. Some persons of 
more mental and nerve force have the fatal power of keeping themselves 
at work or at dissipation till this surplus reserve stock of resistiveness is 
altogether exhausted, and they then become unresistive against morbid 
impulses. Woe to the man who uses up his surplus stock of brain inhi- 
bition too near the bitter end, or too often ! 

In relation to the medico-psychological problems of mental inhibition 
and impulse, we have to take into account those obscure human ten- 
dencies towards killing, towards destructiveness, towards appropriation, 
towards unrule, some of w^hich exist as inchoate physiological tendencies 
more or less strong in most human beings, and the gratifying of which 
gives pleasure. They are best seen in youth, and they often come out in 
a strong way in disease. Be they transmitted qualities of our far-off* 
progenitors, or physiological weapons to help us in the struggle for exist- 
ence, or other and normal physiological energies transmuted, there they 
are, and we must accept them as facts of nature. 

The doctrine of nervous inhibition and of inhibitory centres has done 
very much to definitize our notions in regard to the mental working of 
the brain. There is, of course, no proof of mental inhibitory centres, 
but there is mental inhibition, and a function always implies an organ of 
some sort. When it was demonstrated that the excitation of certain 
nerves caused not motion, but stoppage of motion ; when it was proved 
that the nutrition of the tissues was largely influenced by the increased 
or diminished potency of the capillaries or arterioles, and that the latter 



STATES OF DEFECTIVE INHIBITION. 235 

was dependent on tAvo sets of nerves and two sets of centres, one to open 
and the other to shut those vessels, such physiological facts were at once 
correlated with the facts observed in conditions of mental excitation and 
depression, mental quickening and slowing, emotional supersensitiveness 
and torpor, and the conclusion was arrived at that in the higher depart- 
ment there must be a somewhat similar apparatus for regulating the 
exercise of the mental functions of the brain, and that disorders of these 
would probably make all the difference between sanity and insanity, 
between self-control and insane impulse. That there was a physiological 
analogy between the jactitation of the limbs of a man with chorea, who 
tries to control these motions, but is not able to do so, and the insane 
impulse to murder and violence which the patients are aware of, deplore, 
and fruitlessly try to resist, but are totally unable to do so, seemed very 
evident. In the one case, a controlling centre or centres of motion are 
not doing their work, either from absolute loss of their own internal 
power of governance, or from an excess of energy generated in the lower 
motor centres of the choreic limbs; in the other, the controlling centres 
of mentalization and feeling are not doing their work for the same reasons. 
We know that there are controlling centres of even many of the lower 
reflex functions, and there can be no doubt that they exist also to control 
the great reflex functions of the cerebrum, which were so clearly ex- 
pounded by Lay cock. That doctrine has done much to make us under- 
stand better the mental functions of the brain and their derangements. 
Let us glance at an example. The maternal instinct of care and affection 
for ofispring is a mental function of brain common to man with the lower 
animals, and ranks next to the love of life and the desire to reproduce the 
species in importance, while it surpasses these in conscious intensity for 
the time it is in operation. Its periods of activity are, of course, inti- 
mately connected with the activity of the reproductive organs. The 
objects of the instinct need not necessarily be the animal's own offspring. 
Cats will suckle and take tender care of young rabbits when their maternal 
instinct is in full activity after parturition and when the mammae are 
functionally active. There is a nervous influence sent up from these 
organs to some portion of the brain, rousing it into activity, and so 
developing the feeling for young, and the unceasing innumerable acts of 
care, defence, playing with, and protection, which for the time dominate 
the whole mental life and outward actions of the animal. Artificial irri- 
tation of the mammae without previous parturition .will sometimes develop 
this instinct. In the case of the cat suckling the young rabbits, it 
entirely inhibited the opposite instinct to kill and eat them. In condi- 
tions of disease, the maternal instinct is completely perverted in its 
exercise, so that animals sometimes eat and destroy their young. Now, 
the same thing happens in the human species. In the insanity which 
occurs after childbirth one of the most common symptoms is either an 
entire inhibition of the maternal instinct, so that '^i woman forgets her 
suckling child," or an entire perversion of it, so that she wants to destroy 
her own offspring. 

The physiological word inhibition can, therefore, be used synonymously 
with the psychological and ethical expression self-control, or with the will 
when exercised in certain directions. It is the characteristic of most 



^ 



236 STATES OF DEFECTIVE INHIBITION. 

forms of mental disease for self-control to be lost, but this loss is usually 
part of a general mental affection with melancholic, maniacal, demented, 
or delusional symptoms as the chief manifestations of the disease. There 
are other cases, not so numerous, where the loss of the power of inhibi- 
tion is the chief and by far the most marked symptom. Those we are 
now to consider and study. I shall call this form "Inhibitory Insanity." 
Some of these cases have uncontrollable impulses to violence and destruc- 
tion, others to homicide, others to suicide prompted by no depressed 
feelings, others to acts of animal gratification (satyriasis, nymphomania, 
erotomania, bestiality), others to drinking too much alcohol (dipsomania), 
others towards setting things on fire (pyromania), others to stealing 
(kleptomania), and others towards immoralities of all sorts (moral in- 
sanity). The impulsive tendencies and morbid desires are innumerable 
in kind. Many of these varieties of insanity have been distinguished by 
distinct names. To dig up and eat dead bodies (necrophilism), to wander 
from home and throw off the restraints of society (planomania), to act 
like a wild, beast (lycanthropia), etc. Action from impulse in all these 
directions may take place from a loss of controlling power in the higher 
regions of the brain, or from an over-development of energy in certain 
portions of the brain, which the normal power of inhibition cannot con- 
trol. The driver may be so weak that he cannot control well-broken 
horses, or the horses may be so hard-mouthed that no driver can pull 
them up. Both conditions may arise from purely cerebral disorder, or 
from cerebral excitation or paralysis caused by eccentric agency in the 
organs — it may be reflex, in short. The former of these may be without 
consciousness at all, the ego^ the will, the man being non-existent for the 
time. The most perfect examples of this are murders done during som- 
nambulism or epileptic unconsciousness, or acts done in the hypnotic 
state. There is no conscious desire to attain the object at all in such 
cases. In other cases there are consciousness and memory present, but no 
power of restraining action. The simplest example of this is where an 
imbecile or a dement, seeing something glittering, appropriates it to him- 
self, or when he commits indecent sexual acts. Through disease a pre- 
viously sane and vigorous-minded person may get into the same state. 
The motives that would lead other persons not to do such acts do not 
operate in such persons. I have known a man steal who said he had no 
intense longing for the article he appropriated at all, at least consciously, 
but his will was in abeyance, and he could not resist the ordinary desire of 
possession common to all human nature. I have known a married man 
indulge in masturbation in the same way. He knew it was wrong, and 
he had opportunity of sexual intercourse, but he could not resist this 
simple and unnatural mode of sexual excitation. Volition and resistive 
power were paralyzed. 

The second class of impulsive acts, where we seem to have normal 
volitional power, but the impulses so morbid and so strong that they can- 
not be resisted, is often seen by the physician in the early stages of mental 
disease before its symptoms have fully developed. Its existence may be 
called in question by a i^riori sociologists, may be ridiculed by journalists, 
and the dangers of admitting its existence may be painted in dark colors 
by lawyers, but that it exists as a fact in the history of human nature no 



STATES OF DEFECTIVE INHIBITION. 237 

one can doubt who has actually seen the terror and agony of a mother 
conscious of an impulse to destroy her child, and striving against it with 
vehement resolution. A lady came to me lately to consult me, and this 
was part of her conversation: "Thoughts of putting myself away come 
suddenly into my mind when I am working and quite cheerful. Oh ! 
my God 1 if I could get these thoughts out of my h6ad, what would I 
not give? I could and do scream for relief sometimes. Oh, me! it's 
horrible ! It comes on me that some day I will take aw^ay my life or 
that of my children. I had this idea before I was married at times. 
My mother had it. It comes on me in one instant, and some day I will 
not be able to resist it. It seems now as if there was a galvanic battery 
up from your floor up to my brain that makes my head feel queer and 
tingling. Filthy words and bad thoughts shoot into my mind too in the 
same way." And she threw herself on her knees in an agony of dis- 
tress, beseeching God and me to deliver her from these homicidal and 
suicidal impulses. Yet a minute before she had been cheerful and laugh- 
ing, and a few minutes after she was the same. No doubt the theory of 
uncontrollable impulse is liable to abuse, and to be applied where it does 
not exist ; but one might as well assume that there is no real epilepsy 
because malingerers and hysterical girls simulate fits, or that there is no 
such condition as hypnotism because rogues, fools, and quacks dabble in 
deceit and call it mesmerism. 

The states of defective inhibition and impulse may be momentary in 
duration, or may be constant. They may be slight in form, or most in- 
tense. Their etiology is varied. As a general rule they are met with 
either in those hereditarily predisposed to the neuroses, or in those whose 
normal brain-functions have been impaired by over-indulgence in alcohol 
or nervous stimuli on the part of themselves or their parents. In some 
few cases a merely defective training of the brain in youth seems to end 
in morbid hyperkinesia. No doubt, if we could devise a perfect mode of 
teaching self-control to the young brain it would be an educational dis- 
covery the most valuable yet made by humanity. The great crises of life 
sometimes set up this condition — puberty, adolescence, the climacteric 
period, senility. In many cases there have been congenital or early de- 
fects of brain development, causing volitional and moral imbecility, or 
what Morel called instinctive juvenile mania. Visceral derangements 
and reflex irritations are the causes in many cases. Who does not feel 
his volition or control sympathize with the state of his digestion. I 
knew a young woman who, during menstruation, which w^as with her 
difficult and painful, did all sorts of impulsive acts — eat dirt, hurt herself, 
and pinch children — while she was at other times amiable, and did none 
of these things. There is no doubt that the organic instinct of repro- 
duction becomes transmitted morbidly into instinctive impulses to kill, 
steal, etc. 

I shall confine my observations to the commoner and more typical 
varieties of morbid impulse, and they are the following: <?. general 
psychokinesia ; h. epileptiform impulse : c. animal and organic impulse ; 
d. homicidal impulse ; e. suicidal impulse ; f. destructive impulse ; g. 
dipsomania; /^ kleptomania; ;/. pyromania ; k. moral insanity. 



238 STATES OF DEFECTIVE INHIBITION. 

General psychokinesia or impulsiveness in all directions is well illus- 
trated in the following case, wiio was a patient of mine in Morningside : 

E. L., 93t. 47, of a very neurotic heredity, a brother being epileptic, 
and her sisters very nervous women. In addition to this, she has had 
tw^enty years of sorrow and domestic worry, with a drunken husband 
who could not provide for her, and through the loss of several of her 
children. She has had ten children and nine or ten miscarriages. The 
children whom she lost all died of convulsions or hydrocephalus. The 
exciting cause of her illness w^as an abortion at two months. She was 
most impulsive on admission in all ways. She tore her clothes, she tried 
to jump out of windows, she refused food at times when she did not get 
what she wanted, she would do any mischief that was in her power. Be- 
tween those acts she was rational in speech and conduct, affectionate, and 
agreeable. She w^ould be dancing, lively, and chatty in the drawing- 
room, apparently one of the happiest women there, and, seeing an open 
window, she would suddenly change in expression of face and eyes, would 
step towards it, and try to throw herself over. When asked about it, she 
would say she could not help it. She was always most impulsive at the 
menstrual periods, and at these times frequently had retention of urine, 
needing the catheter (this she had been subject to occasionally during her 
married life). The bromides, fattening non-stimulating foods, fresh air, 
baths, and constant supervision and occupation were all tried, with a 
gradual good effect. The impulses became less intense, and her self-con- 
trol more, as her bodily condition improved. She was subject to sudden 
feelings of what she described as ''unutterable dread and woe," coming 
like a flash over her and passing away as quickly. Unfortunately at 
first we gave her chloral and hyoscyamus at night, which I found was a 
mistake. She became very dependent on these things for sleep. She 
did much better when they were stopped. Now I never give chloral con- 
tinuously where there is impulsiveness. I believe that its effect is to 
lessen the inhibitory mental power of the brain. In about three years 
she had improved considerably, and was removed to another asylum ; but 
she is impulsive still at times, though not dangerously so. It must be 
remembered that all these impulses, obstinacies, violences, destructive- 
nesses, and suicidal attempts were most contrary to the whole habits of 
the life of this lady till she was forty-seven, that they then lasted more 
or less for nine years, and now she has got rid of them to a very large 
extent ; and that between those acts of want of inhibition she was one of 
the most agreeable and sensible persons I ever saw, and was clever, witty, 
and often hilarious. 

The next case was a patient of mine, and was well described by one 
of the assistant physicians here, Mr. James Maclaren.^ I look on it as 
being generally impulsive and to some extent epileptiform in character. 

"Late one night a lady, whom we shall know as E. M., was brought 
to the Royal Edinburgh Asylum, laboring under great excitement, and 
bleeding from wounds in her mouth, caused by her attempts to swallow 
pieces of the glass of a cab window which she had broken. Her insanity 
was very early seen to be of a kind in which the leading features were 

1 Medical Times and Gazette, January 8, 1876. 



STATES OF DEFECTIVE INHIBITION. 239 

impulsive acts of a sudden and a most dangerous character to herself and 
to others. She is not an epileptic ; she has no delusions or hallucina- 
tions, or, if she is possessed with the former, they are of a kind belong- 
ing more to a mild state of dementia than anything else, and are fleeting ; 
and she has at any time only occasional and often no consciousness of the 
irresistible impulse which is frequently put down as the cause of danger- 
ous acts otherwise difficult to account for. In her the paroxysm of vio- 
lence has the following characters : It is periodic ; it is accompanied by 
-always partial, frequently total unconsciousness, and consequently fol- 
lowed by a similar state of forgetfulness of her acts ; it is preceded by 
sharp pain in the head, and followed by a dull pain in the head, dizzi- 
ness, and confusion of ideas. There exist also certain neuroses, but these 
will be detailed in the course of the history of her case, which it will be 
well now to enter on. 

" She is forty-three years of age, the fifth child of a family of fourteen. 
Her parents are both of a neurotic type ; her father is almost totally deaf, 
and a brother of his died insane. That is not a very strong neurotic 
history perhaps, but, making allowances for the possible reservations of 
sensitive relatives, it indicates a decided tendency to nervous weakness. 
Her mother dwells on the border-land of insanity; she was always a 
person of very peculiar disposition, suspicious, unreasonable, and of an 
exceedingly high-strung and nervous temperament. This was her con- 
dition previous to marriage. Its cares and troubles, and particularly the 
mental and physical wear and tear involved in the bearing and nursing 
of fourteen children, told badly on her. Her confinements were severe, 
and after them she was subject to alarming floodings; at her menstrual 
periods, too, the hemorrhage was always excessive. That all this told 
on her severely was noticed by her friends in her increasing debility, 
nervousness, eccentricity, and irritability as she advanced in years, and, 
to anyone who could read the lesson, was confirmed by what seems to me 
a very curious fact. She had, as I have said, fourteen children. The 
first jpour of these were fairly healthy, and are still living ; then came the 
subject of the present note, regarding whose mental and physical health 
we shall presently hear ; and after her came nine children, all of whom 
are now dead. The elder ones lived longest, and then, as the mother 
grew in years, and the strain on her became greater, the duration of the 
life of her offspring shortened. It is true that none of them died di- 
rectly from brain disease ; still it does not seem too much to assume, with 
the history I have described, that the parents were at first able to pro- 
create healthy oifspring, that this began to fail with E. M., and that after 
her the strain became greater and greater, and so they produced children 
only in the poorest degree endowed with the power of living. The in- 
verse ratio between the age of the parents and the duration of life in the 
offspring seems too marked and definite to be due to accident or chance. 
So, then, in this neurotic couple we have them in their earl}^ married life 
transmitting to their children health, later on insanity, and ultimately a. 
tendency to early death. 

"And here, forestalling its position in the liistory of her case, comes 
in another step in the descent and progressive degeneration. E. jNI., has 
become pregnant several times — one child is alive, one lived a few mouths. 



240 STATES OF DEFECTIVE INHIBITION. 

all the rest were born prematurely. The child which is alive is, as re- 
gards his mind at present, precocious and talented, writes letters in a 
style beyond his years, reads books on natural science, and is fond of 
sketching and painting, and thought exceedingly gifted by his friends. 
With the history I have detailed, and after this description, it is almost 
superfluous to say that he is stunted in body, weak, and miserable, and 
often barely kept alive by constant and most careful nursing. 

"I have now to speak of the personal history and characteristics of 
the unfortunate lady who is the subject of this sketch. As I have said, 
she was the fifth child of her parents. In her early years she was only 
noted for everything that was good and amiable. In this I am not taking 
the words of possibly too partial friends, but of others who knew her 
more or less intimately ; and one and all bear testimony to the fact that, 
as regards the possession of many good qualities, she was far above the 
average. Kind and loving, very gentle and quiet, but apt to become 
emotional on trifling provocation ; devoted as far as her strength per- 
mitted to all good works, generous even to a fault, and earnest in season 
and out of season to do her duty, — such is the account of her in her 
early days. From her earliest years religion was part of daily life, not 
engrafted on to her other duties, but forming the moving principle of all 
she did. She belonged to a devout family and a devout sect, and so, by 
education as well as temperament, was thoroughly and entirely devoted 
to sacred thoughts and duties, and was noted among her friends for the 
emotional fervor and power of her prayers. In ability, too, she was 
above the average — clever, studious, and painstaking. 

"At the age of twenty-three she married her present husband — a gen- 
tleman in every way calculated to make her happy. It was long before 
he noticed anything particularly strange in her manner or conduct. Cer- 
tain slight peculiarities, a morbid sensitiveness as to possible wrong-doing, 
occasionally excessive emotionalism, and once or twice, when in circum- 
stances calculated to excite or distress her (such as being in the company 
of uncongenial people or those of a higher social rank), a tendency to 
become rambling and incoherent, — these were, as far as he can remember, 
the only facts that called for notice or excited alarm. Still it was of the 
slightest ; for she had always been somewhat unlike other girls of her 
age, and inclined to strange and wayward (though serious) turns of 
thought and expression ; and for long the knowledge of this prevented 
much or any attention being paid to passing acts of eccentricity or un- 
wonted modes of speech. Excepting these (and they had been so slight 
that it is only now, on close inquiry being made, that they are recalled) 
she for long after she was married led the same kind of life she has been 
described as doing before, and was foremost in every good work and kind 
action. Still, it is not difiicult to trace the gradual invasion of the malady 
of which she is now the victim. 

" Some years after she was married, and ten years ago, the boy already 
mentioned was born, but previous to that, and since, she had several 
times aborted. On each occasion her bodily weakness from excessive 
flooding was great, and her mental distress at the unfortunate issue very 
painful. Two years ago she again became pregnant, and, greatly to her 
joy, was delivered of an apparently healthy boy, and for a little while 



STATES OF DEFECTIVE INHIBITION. 241 

the caring for it seemed to restore the balance of her mind. However, 
it was only spared to her for a few months, and its death and the final 
and marked access of her insanity occurred to her. During her preg- 
nancy, and for some months before, the little abnormalities I have men- 
tioned were beginning to become more and more marked. Her religious 
feelings became of the most exalted character, and her emotionalism ex- 
cessive. On one occasion, while walking with her husband in a fre- 
quented place, she knelt down and prayed for strength to bear her coming 
trial ; and her benevolence and generosity, always prominent features in 
her character, became almost unbounded, and frequently quite unreasona- 
ble. When the baby came, her attention was taken up with it, to the 
exclusion of everything and every one else. Then it was taken away, 
and from that time is dated the marked unmistakable arrival of the in- 
sanity. General excitement, an altogether morbid and excessive fear 
regarding her religious state and future salvation, and an excessive sensi- 
tiveness as to the possibility of ever having in any way wronged any one 
with whom she might have had dealings, were the early symptoms she 
displayed. Then sudden and unaccountable outbreaks of dangerous 
violence, attempts at self-destruction occasionally, and most destructive 
tendencies in every respect, rendered her removal to an asylum impera- 
tive. She was accordingly taken to a private establishment, where she 
remained for a few months, gradually getting worse and worse. During 
this time a hsematoma of the left ear developed itself, and ran the usual 
course,, leading to the shrivelled and characteristic insane ear. She was 
brought, as I have said, to Morningside last July, with the reputation of 
being a patient most dangerous to herself and others, and requiring con- 
stant and careful watching and, supervision, and she has more than justi- 
fied all that was said of her. She had not been long a patient before it 
was noticed that her case presented many points of singular and great 
interest. Her constant and seemingly unwearied attempts to commit 
some destructive act, and the care and ingenuity required to baffle these, 
made her an object of much thought and no little anxiety; but quite 
apart from that, which is not so very rare an experience for an asylum 
officer, there is in her case such an amount of strange contradiction, and 
contrast of light and shade, as to make her a puzzling and interesting 
study. Instead of extracting the details of daily entries in the case- 
book, I will endeavor to give a brief sketch of what manner of woman 
she is. 

"First, as to her appearance — she is slight and almost undersized, a 
very gentle-looking lady, with a pale, pretty face, light hair, and blue 
eyes, a singularly kind, pleasant, winning manner, and a soft, quiet 
voice. Second, as to her mental state — free from excitement, she is 
what she has already been described as, thoroughly devout and good. 
Her memory and judgment are in all but one respect correct. Thoughts 
of her husband and child, bitter regret at her separation from them and 
at her sad calamity, a constant and prevailing desire to do what is right, 
and an excessive and morbid sensitiveness lest her slightest word, or 
look, or action may be in any way wrong. That is the bright side of the 
picture of a singularly pure but sadly imperfect nature. Now for the 
reve7'se. 

16 



242 STATES OF DEFECTIVE INHIBITION. 

"It is difficuH in a 23eii-and-ink sketch to give an idea of the intense 
impulsiveness of her acts. I am not at all exaggerating when I say that 
little short of being possessed bv the devil would account for her conduct.. 
She will sit reading her Bible or some good book, or talking in her quiet, 
gentle way to her attendant, when suddenly, without a moment's warning, 
the book is flung through the nearest window, or at whatever is breakable 
at hand, then she makes a rush to run her head into the fire, or turns on 
her attendant, tears her clothes, or tries to strangle her. All this without 
speaking a word, except, perhaps, an occasional muttered text of Scrip- 
ture; but, beyond that, she keeps quite silent, and struggles on quietly 
but fiercely, till either exhausted, or restored by some apparent process of 
awakening to her former condition. Excitement, of course, there is in 
plenty, but it is very different from that associated with more ordinary 
forms of mania. There is no noise or shouting; her eyes are fixed and 
suffused, her face flushed, and her teeth clenched, and every muscle is on 
the strain; but the whole time she is perfectly quiet, and struggles on 
with a fixed, determined purpose expressed in her whole manner, but 
without wasting a word. 

"There is no use dwellino; too lono- on the various destructive acts that 
she has committed. I might, I believe, go on for hours, and not have 
completed the list. Suf&ce it to say that there is hardly a method of at- 
tempting violence that the mind could conceive, that she has not had re- 
course to. At one time, but only for a few weeks, her acts took the form 
of exposure of her person, and in this, too, suddenness was the marked 
feature. I have seen her weeping bitterly at the sadness of her lot, and 
praying for some help, and while the words were still on her lips, throw 
herself on the ground, and pull up her dress. Once or twice about this 
time there was a slight increase of her general excitement, and she laughed 
and talked more than usual ; but as a rule the exposure was something 
altogether different from the ordinary suggestive act of an erotic female. 
This tendency to exposure, however, did not last long, and has not re- 
turned. 

"Now as to the nature of her paroxysms. Though not very definite, 
there is no doubt that there is a certain amount of periodicity in them. 
It is not hard and fast, but her attendants notice that she has, as they 
put it, a good day and a bad one, or two good days and two bad ones. 
The suddenness of their arrival has been already dwelt on. She often 
suffers sharp pain in the head for a longer or shorter time previous to an 
attack, but the transition from perfect quiet and gentleness to her wildest 
paroxysm is instantaneous. Then (and this seems to me a very impor- 
tant point in her history) there is, as a rule, entire unconsciousness and 
forgetfulness of what passed during an attack. I have often taken her 
careftilly over the events of a day in which one had occurred, and in- 
variably found her correct and precise in every detail till we reached the 
onset of the seizure. Then all was a blank, and she only remembered 
that she seemed to faint, and then found herself lying on a sofa with an 
aching head, and confased and stupid. Occasionally, and if her seizure 
has not been very severe, she has some slight recollection of her act and 
of the impulse which led to it, and the latter is always a feeling of im- 
perative necessity that it is her duty to do as she has done ; but in by 



STATES OF DEFECTIVE INHIBITION. 243 

far the greater nuraber of her attacks, unconsciousness during and after 
was the rule. 

" There are a few physical phenomena connected with her case that I 
will now mention. The insane ear has already been recorded. Her 
tongue is tremulous and points markedly to the right side. After an 
attack she has a slight stutter and thickness of speech. The right pupil 
is more dilated than the left. During a paroxysm both pupils dilate and 
contract constantly and independently of each other, so that sometimes 
one and sometimes the other is the more dilated. Her hair is exceed- 
ingly dry ; her temperature is normal, with a steady increase of two 
points in the evening over the morning figure. Her menstruation has 
not returned since her last child was born. Her sensibility is at all 
times dulled ; during an attack it is greatly impaired. The reflex action 
of the cord is much dulled. 

"What is the nature of her insanity? Her attacks, read alone, seem 
only to want one factor — epilepsy — to make all complete. This, though, 
is wanting; she is not epileptic now, and has never been so; and her 
present attacks, though bearing not a little resemblance to it, are not 
epilepsy. That her motor centres and the circulation in her brain are 
diseased, the outward signs I have tpld show, but that only leads us half- 
way, if so far. Why is it that this gentle, loving lady, who mourns her 
affliction so greatly, and who would fain struggle against it, so that she 
might return again to her husband and her child, — why is it that at the 
very moment she is penning kind words to them, or thinking kind 
thoughts of them, she should be dragged into the committing of acts 
which she abhors, and of which she is happily unconscious ? And yet, 
though in her calmer moments she is oblivious, still these acts were gov- 
erned by a direct controlling will — they had an object, and Avere carried 
to a definite end. 

"It is a strange condition of dual consciousness. Whether she re- 
members in each paroxysm what happened in the last I cannot say, but 
I think she does, and it is certain that she follows out trains of thouo-hts 
in successive attacks, of which she has no consciousness during a remis- 
sion. For instance, of late, as soon as a seizure comes on her, she 
makes particular efforts to get at one special picture in the room. When 
the attack has passed, this picture awakens no feelings in her at all, and 
she has no recollection of anything particular connected with it ; but as 
soon as the excitement returns, her attention fixes on it at once."' 

In the course of three years she gradually became less dangerous, and 
the impulsive attacks less intense, wdiile her mind became more enfeebled. 
She got so much better that she was taken home under the charge of a 
nurse, and is now, after seven years, almost demented, and of course 
quite incurable. The impulsiveness has almost disappeared. 

Epileptiform Impulse. — E])ilepsy, as we shall see in the psychosis 
commonly associated with it (epileptic insanity), tends remarkably 
towards impulsive acts, which will be considered under that form of 
insanity. By epileptiform impulse I mean those sudden impulsive acts 
attended by unconsciousness, which are exactly the same in character as 
those we are familiar with in e})ileptics, and yet the patients are not 
subject to ordinary epilepsy. Hughlings Jackson, I sup})ose, wimld call 



244 STATES OF DEFECTIVE INHIBITION. 

them cases of mental epilepsy. Some of the acts of E. M. were clearly 
of this character. I have now a patient who brought on his disease by 
over-drinking, and who on one occasion leaped through a window on the 
third story when quite sober, and did not know anything about it after- 
wards. On another occasion, in passing the corner of a building in the 
asylum, he ran violently against it with his head, causing a wound five 
inches long, and very nearly breaking his skull-cap. He is not a regular 
epileptic, but he once took a convulsive epileptiform attack. His case is 
incurable, as he is now getting demented, and his impulsiveness is 
passing off. The regular use of the bromide of potassium seemed to 
diminish the impulsive tendency. 

Animal and Organic Impulse. — Under this term I include all the 
nncontrollable impulses towards sexual intercourse, masturbation, sodomy, 
rape on children, bestiality, etc. The perverted instincts, appetites, and 
feelings shown in urine drinking, eating stones, rags, clay, nails, etc., 
come under this heading too. There are few cases of mental disease 
where some appetite or instinct is not in some degree perverted or 
paralyzed. But there are cases where such things are so prominent 
as to constitute the disease. I have a patient who assures me that his 
desire to masturbate is an irresistible craving which he has no poAver to 
control. Here is a girl who rubs her thighs together to produce sexual 
excitement the moment she sees a man. Here is a case of nymphomania, 
who rushes towards any man she sees, and can scarcely be held by two 
attendants. I believe there are cases in which there are irresistible 
impulses towards sodomy and incest. Many of the men who commit 
rape on children are insane. I lately had to give evidence at the 
Carlisle Assizes about the insanity of a medical man who had tried to 
commit rape on three children under age in succession. No doubt he had 
the delusion that God had in some occult way revealed to him that 
he should beget a male child, and had sent the little girls to him for this 
purpose ; but he was practising his profession up to the commission 
of the act. I have referred to the case of the young woman who had an 
impulse to eat clay and dirt every time she menstruated. She could not 
help it, and had no such tendency between. A shoemaker patient in the 
Prestwich Asylum swallowed a few shoe-nails every day, and, what was 
strange, was none the worse. There is an infinite variety of such 
impulses. Erotomania is applied to those cases where there is an 
intensely morbid desire towards a person of the opposite sex, without 
reference to the sexual act. It is a sort of exao:o;erated and insane state 
of "being in love." 

Homicidal Impulse. — Homicidal impulse is often spoken of by 
lawyers, publicists, and ignorant persons, as if it were a thing that did 
not really exist, but has been set up by the doctors to enable real criminals 
to escape justice. Here is a letter from a former patient of mine, E. N., 
a medical man of perfect truthfulness and great benevolence of character, 
written to me when he was convalescent : 

My Dear Sir, — According to promise, I have written to the best of my ability what 
I feel mentally. God alone knows my feelings. They are truly awful to know. I lived 
in continual fear of doing harm each day. I had not a moment's peace in this world. 
I have been in practice for twenty-three years, and have attended 2550 midwifery 



STATES OF DEFECTIVE INHIBITION. 245 

cases, which used to take the life out of me more than anything else. I often used, 
when busy, to attend to 60 or 70 patients a day at home and out, and in the winter used 
to average 28 a day at their houses. 1 have had no holiday for many years. I did not 
think I was laying the seeds of brain disease, but such has been the case in the most 
dreadful form. I loved my dearest wife and little ones most dearly, and my home used 
to be so happy and cheerful after my hard work. You are aware I had a very long illness 
in bed, had several operations, erysipelas, &c. Two years previous to this I had a fall 
on my head, which stunned me at the time. I may say I have never felt really well 
since the fall, though I did my practice. I had occasional strange feelings, but those 
were only known to myself, being ashamed to mention them ; in fact all the time, up 
to within a short time of coming under your care, I appeared cheerful and even jolly. 
But when in a train I was afraid I should jump out of the window, and when I saw 
one in motion I felt I must jump under it. I was afraid, when applying nitrate 
of silver to the throat of my patients, that I should push it down. I was terrified to 
apply the midwifery forceps, lest I should not be able to resist the impulse I had to 
drive them up through the patient's body. When opening abscesses I felt as if I must 
push the knife in as far as possible. When I sat down at my own table I used to have 
horrible impulses to cut my children's throats with the carving knife. At the sight of 
pins I had a feeling as if some had got into my throat, and I could not divest myself 
for some time of this feeling. I had other strange feelings which I can hardly 
describe. Whenever I saw a knife, razor, gun, etc., I was afraid I should do harm 
by a sudden impulse, the will having hardly the power to resist. I took opium 
several times from no deliberate intention, but by a sudden impulse that I could not 
resist when I was working with it in the surgery, but I vomited it. 

My brain feels quite dead, with no feeling in the scalp ; my eyes seem as if some- 
thing were dragging at the optic nerve continually. In the left I have a most 
unpleasant feeling to bear, and I cannot 'see distinctly with it. There appears to be 
something floating in front all the time like a dark shade. I should say I am, and 
have been, suffering from homicidal monomania and moral insanity, and have been 
since June last, although a part of the time doing my practice and living with my 
family. I thought I could shake it off, but such was unfortunately not the case. 

Thanking you most sincerely for the kindness and attention shown to me since I 
have been a patient in this asylum, I am, dear sir, yours faithfully, E. IST. 

Now this is either a tissue of lies, or the thing homicidal impulse 
exists. This unfortunate man had placed himself in the asylum of his 
own accord, and he took a gloomy view of his prospects of recovery. I 
did not do so, but assured him he would recover, and adopted every 
means for that purpose ; gave him tonics, got him employed and interested, 
made him live in the fresh air, and go to all sorts of amusements in the 
asylum and out of it. I am glad to say he recovered, and went into 
practice, and unfortunately got as much to do as ever, and relapsed. 
This time he showed his impulsive tendency and loss of inhibition 
by taking to drink, which looked like a symptom of his brain disorder. 
By temperament he Avas a sanguine man, strong, hearty, robust, and 
jolly. In fact he was a perfect Mark Tapley in his unfailing cheerfulness 
under difficulties and disasters. He was an immense favorite with the 
ladies here, and to see "the doctor" being taught by them to dance 
a Scotch reel was a sight far away from any suicidal or homicidal idea. 
Yet in the midst of this a dark shadow would sometimes cross his face, 
and he would say to me, " Oh, doctor, these strange feelings : if they 
would only keep away I should be as ha})p3^ as I look." 

Tliis is merely one case, but it is a typical one. E. N. had no insane 
delusions, he could reason well ; affectively he was fond- of his wife and 
fiimily and friends ; he had not a cruel or criminal disposition — quite the 
reverse ; he had no outward excitement, no signs of outward depression 
like an ordinary melancholic patient ; his mind was not enfeebled, yet he 



246 STATES OF DEFECTIVE INHIBITION. 

wanted to kill his patients and his children, and had much difficulty in 
restraining himself from doing so, and he actually could not restrain 
himself from suicidal acts. All these feelings were connected with an 
original heredity to mental disease, with a brain exhausted by hard work 
and no rest, and with a running down of his general vital power by the 
bodily disease he had lately suffered from. They had as their accompani- 
ments those marked sensory and special sense feelings described in his 
letter, which were really an essential part of his trouble. They disap- 
peared under rest, change, proper medical and moral treatment. The 
whole affection was just like many other diseases in its causation, 
inception, and recovery. What room, therefore, is there for doubt that 
such a disease exists ? 

That the theory of uncontrollable homicidal impulse should have been 
used in courts of justice to screen real murderers or would-be murderers, 
is surely no reason for disbelieving important facts of disease. It is our 
duty as medical men to examine carefully the evidence in every case 
where a homicidal impulse theory is set up to explain crime, to look on 
any such case suspiciously perhaps, to search for other symptoms and 
causes of mental or nervous disease accompanying it, but we must not be 
frightened by the lawyers into blinking real facts and real disease. 

Homicidal impulses in a mild way are very common indeed in the be- 
ginning of mania and melancholia. Patients feel as if they must kick 
and strike those near them, and they often do so. It is a relief to them 
to do so. Such impulses are often part of the nervous disturbances that 
accompany puberty, disordered menstruation, childbirth, lactation, and 
the climacteric period in women. I once saw in gaol a girl of thirteen, 
Avhom I had no doubt had without motive killed a child entrusted to her 
care, though there was no legal proof of it. Margaret Messenger, a 
little girl of thirteen, was proved at the Carlisle Assizes, 1881, to have 
drowned a child of six months, of which she had charge, and she had 
previously killed its brother. Like all such cases, she had no motive, 
and showed no mental excitement or depression. She could not be made 
to realize the gravity of her situation or the awful nature of the crime 
she had committed. This paralysis of feeling and of fear is very char- 
acteristic of such cases. She was described as "a typical country girl 
of her age, fresh, tidy-looking, and fairly intelligent." She was quite 
composed through the trial. After her conviction she confessed that she 
had killed the brother b}^ throwing him into a well, in which it had been 
supposed he had fallen accidentally. I had a patient last year, E. N. A., 
a lady with a child five months old when I saw her, and who, on medical 
advice, left her home on account of a morbid dislike to her husband and 
child, and homicidal impulses towards them. During her pregnancy she 
had the same kind of dislike to her mother. She deplored these morbid 
desires to kill her husband and child intensely, because she was devoted 
to them, and a most affectionate Avoman. She had suicidal impulses too, 
but not so strong. These were not the only symptoms of disease. She 
suffered from dull headaches, twitch ings on the right side of her face 
when she spoke, impaired sleep, fever, slight albuminuria, aggravation of 
all her symptoms in the mornings, screaming fits, Avant of appetite, thin- 
ness, and a pigmented skin. Through change, absence from home, milk 



STATES OF DEFECTIVE INHIBITION. 247 

diet, exercise in the fresh air, iron, claret, and pleasant companionship 
and travel, she recovered in about four months, getting stout, fresh-col- 
ored, and menstruation becoming regular. I have referred to the case 
of B. R. (p. 112), a climacteric case, and her tendency to kick, strike, 
and pinch her fellow-patients in the morning only, while in the evenings 
she would be cheerful, would dance, and enjoy herself. I have now a 
man, E. N. B., with a neurotic heredity, an uncle being epileptic, who, 
when sitting at a window^, dropped a big stone on to the top of the head 
of a casual passer-by, against whom he had no ill-feeling whatever. 
After he was sent to the asylum we could see nothing wrong with him 
till one day he tried to stick a dung fork into an attendant. He seemed 
to recover, and, after a long time of probation, he was discharged, but 
very soon ran after a relation with an open knife. He was sent back to 
the asylum, show^ed no signs of insanity at first, and then his mind grad- 
ually became enfeebled, and he is now nearly demented, just as he would 
have been had his attack been one of mania. Homicidal impulse is thus 
seen to end in dementia if it lasts long, like any other kind of mental 
disease. I have even seen a homicidal stage in the beginning of general 
paralysis. 

Suicidal Impulse. — I am speaking here, remember, of suicide as an 
impulse unaccompanied by any marked mental depression or delusion. 
The following two cases exemplify what I mean : 

E. 0., a young man of eighteen, of nervous heredity, with no par- 
ticular cause of mental or bodily disturbance, except perhaps an unre- 
quited love fancy for the scullery-maid. He being an assistant to a 
butler in a gentleman's family in Cumberland, seemed in good health, in 
good spirits, and was washing the dishes after lunch one Sunday. His 
master, from the dining-room, heard a peculiar sound in the pantry, and, 
going to see what it Avas, found E. 0. hanging by the towel with which 
he had been wiping his dishes, his face livid, and nearly dead. After 
being taken down he was unconscious for some hours, and then confused 
in mind for a day or two. He was sent next day to my care at the Car- 
lisle Asylum, and I found him confused, and his memory defective. He 
could give no account whatever of the suicidal attempt, and w^as rather 
inclined to deny it, but the evidences of it were well marked on his neck 
and face. There was no mental pain, and no delusion. He did not 
sleep very well. He was sent much into the open air, and was ordered 
a little bromide of potassium. In a week there was not a trace of any 
mental defect whatever. He was not a strong-minded youth, but not 
imbecile. He maintained through many cross-questionings that be never 
had a conscious intention or thought of putting an end to himself in his 
life ; that he remembered events quite well up to a certain moment on 
the Sunday he was washing his dishes, but after that he had no recollec- 
tion of anything whatever till the evening. I had no reason whatever to 
doubt the correctness of his statements, which were confirmed to mo by 
the butler. He kept quite Avell when last I heard of him. 

E. P., a young professional man of thirty, whose father had been sub- 
ject to "depression of spirits," and who had had chorea in his youtli, but 
who was clever, cheerful, good principled, religious, and successful. He 
was happily engaged to have been married in a fortnight. He luul boon 



248 STATES OF DEFECTIVE INHIBITION. 

spending the evening with some friends, and was in first-rate spirits. 
No melancholy or morbidness whatever had been seen in him. He had 
remarked to some friend casually some weeks before that he had to hold 
his head in a particular way or he saw things double. He took a hearty 
supper, and went to his bedroom. In the morning his body was found 
suspended to a cupboard door by the worsted cord of the window curtain. 
He had undressed, and then, evidently without preparation or contrivance 
of any kind, taken the cord, which was sewn in a circle, thrown it as a 
loop over the top of the half-open door, put the other end of the loop 
under his chin, and, pulling up his feet, suspended himself. There was 
a strong presumption that it was not a conscious, premeditated act. We 
found a large ossified spiculum of bone projecting from the dura mater 
into a convolution at the vertex at the junction of the anterior with the 
middle lobe, the arachnoid thickened, and the whole brain intensely con- 
gested. I considered the case one of unconscious suicidal impulse of an 
epileptiform nature. Such irritating spicula of bone of course oft^n 
cause ordinary epilepsy, and this is not the only case of impulsive in- 
sanity in Avhich I have met with the same pathological appearances. 

Those were cases of morbid suicidal impulses accompanied by uncon- 
sciousness. Such cases are rare. But cases like the following are very 
common in the experience of most medical men. The classical tedium 
vitce was somewhat of this character, looked at medico-psychologically. 

E. P. A., a man of fifty-five, who had been healthy and lively. For 
some months his enjoyment of life has been less intense, but he has had 
no real mental pain. For a few^ weeks he has had a strong impulse to 
take away his life, and the sight of a knife at once suggests this to his 
mind at any time. He has no delusions whatever about being wicked, 
etc. He deplores the feeling, and it annoys him, and he thinks himself 
"a fool" for harboring "such nonsense" in his mind, but he cannot help 
it. The only thing wrong with him is this, that he cannot sleep very 
well. Change of air and scene, after about two years, seemed completely 
to drive away the suicidal feeling, but his mental condition after it passed 
off was somewhat senile, his ambitions, desires, and enjoyments being 
toned down, and all the keen edge of his life taken off. 

When the impulse is towards self-destruction, even the lawyers do not 
deny its existence or try to reason facts away. And they cannot attri- 
bute any sufficient ''motive" for such persons as E. 0. and E. P. putting 
an end to themselves, though this notion of a "motive" for suicide seems 
ineradicable in the public mind. Who ever saw an account of a suicide 
in a newspaper without an explanatory remark that "the motive for the 
rash act has not been ascertained ?" It is impossible to tell how many 
of the sixteen hundred annual suicides of England are the result of mere 
impulse, apart from mental depression, delusion, or alcoholism. It is 
common to find the suicidal and homicidal impulses combined, as in the 
case of E. N. (p. 244), to which I have referred. 

Destructive Impulse. — In childhood there exists, from pure accumu- 
lation of motor energy, that must be let off somehow, a desire to play, 
to romp, to move, and to destroy. Most people experience a morbid 
muscular activity when they have " the fidgets," and few people but have 
the feeling sometimes that they would like to break glass or smash some- 



STATES OF DEFECTIVE INHIBITION. 249 

thing. In many forms of mania and in excited melancholia we have 
destructive tendencies as one symptom of the general psychosis. In high 
emotional tension women often feel as if they must cry or break some- 
thing, and many women in prison take regular periods of " breaking 
out," during which they tear and destroy clothes and property without 
regard to punishment or to consequences. In the first stage of general 
paralysis the morbid motor activity usually takes the form of tearing, and 
it is common for such cases to have all their blankets torn to shreds every 
morning, and their clothes during the day. But the same uncontrollable 
desire to tear or break may exist alone, without much outward exaltation 
or depression.' 

I have now a young man of twenty-five, E. P. A., whose mother was 
insane and his brother paraplegic, who for two years required the constant 
vigilance of an attendant to prevent him breaking windows and tearing 
his clothes. He actually broke over one hundred small panes of glass, 
and tore one hundred and fifty pairs of trousers. The reason he 
assigned for this was that he could not help it, and that it was " my 
conscience checking me " that did it. He was quite sprightly and jolly, 
would work in the garden, would dance at the ball as lively as anyone, 
and was never suicidal or homicidal, yet when he saw a window near, 
he would eye it as if fascinated, and, if he had a chance, would spring at 
it and smash it, or throw something at it. He said it gave him great 
relief when this was done. He seemed to grow out of this tendency as 
he became more demented, which he did gradually. The habit of mas- 
turbation increased the tendency in him, and hard work in the garden 
ordinarily diminished it. The bromide of potassium and cannabis Indica 
kept it in check. 

I show you another patient, F. F., of twenty-two, who suddenly when 
at sea took " smashing fits," the description of which by Dr. Logic, his 
family medical man, was as follows : " His bodily health is good, but he 
is subject to sudden fits of something like insane impulse, continuing 
sometimes for a few minutes only, and at others for a whole day. During 
their continuance he has no control over his actions. He says he knows 
he is doing something which he ought not to do, but he cannot help it. 
At one time the presence of the fit is manifested by his roaring aloud 
and using very bad language ; at another he will suddenly jump up, 
seize a chair, dash it with violence on the table, smashing to atoms dishes, 
cups, and saucers, or whatever else may happen to be on the table. 
When in these states he is exceedingly violent. When interfered witli on 
one occasion he knocked his mother down, and on another threatened to 
shoot his father, who was trying to control him. Unless when the fits 
are on him, he is perfectly quiet and reasonable. He believes that 
the fits are occasioned by a person who has power over him, and can 
make him do as she likes, and that slu^ first obtained that power by 
putting something in his tea." After admission lie would bo rational and 
self-controlled before these attacks, and again after. He still has the ten- 
dency, though it is less intense and less frequent. As the period of 
adolescence is passing into manhood and his beard is growing, I expect 
him to recover. I watched him one night at a dance. He looked absent- 
minded, and aimlessly restless. I spoke to him, and he answered me 



250 STATES OF DEFECTIVE INHIBITION. 

rationally. He looked pale, and his eyes were glistening. He stepped 
towards a window, and suddenly smashed it with his hand, causing 
a wound. At once he seemed to get calm and quiet, and felt relieved. 

We had on two occasions as a patient in Morningside a man named 
James Morrison, who at intervals of several years had left his home in a 
Fife village, where he worked as a weaver, and had gone to Glasgow 
once, breaking some windows in the Cathedral, and to Edinburgh twice, 
breaking some large plate-glass windows in shops, always quite coolly, by 
throwing stones at them. After coming to the asylum we could scarcely 
ever detect any symptoms of mental disease. He seemed to have 
expended all his morbid energy in the one act each time. He was a man 
of neurotic heredity and good character, who had no motive for getting 
into goal. He always said he could not help smashing windows ; that 
the desire to do so used to come on him in his home in the Fife village, 
along with a restless, unsettled feeling ; that he did not break the windows 
in the houses of his village because they were too small and " not worth 
breaking." It evidently would have given no satisfaction to his morbid 
desire to break them. I presume his was just a strong and uncontrollable 
form of the feeling which many men have who stand before a big plate- 
o[lass windoAV with a cricket ball in their hands. 

Dipsomania. — This is a misnomer ; we do not mean an insane craving 
to drink. What is meant is a morbid uncontrollable craving for alcohol 
and other stimulants. What we really want is a good word to express the 
cravings for all sorts of neurine stimulants and sedatives, as well as 
alcohol. The confirmed opium eater, the inveterate haschisch chewer, 
the abandoned tobacco smoker, are all in the same category. No medical 
man who has been long in practice can doubt for a moment that there are 
persons whose cravings for these things are uncontrollable, and who have 
therefore a disease allied to all the other psychokinesise. Particularly 
the morbid craving for alcohol is common, and so intense that men who 
labor under it will gratify it without regard to their health, their wealth, 
their honor, their wives, their children, or their soul's salvation. Certain 
causes predispose to it. These are (1) heredity to drunkenness, to 
insanity, or the neuroses ; (2) excessive use of alcohol, particularly in 
childhood and youth ; (3) a highly nervous diathesis and disposition 
combined with weak nutritive energy ; (4) slight mental weakness con- 
genitally, not amounting to congenital imbecility, and chiefly affecting 
the volitional and resistive faculties ; (o) injuries to the head, gross 
diseases of the brain, and sunstroke ; (6) great bodily weakness and 
an?emia of any kind, particularly during convalescence from exhausting 
diseases ; (7) the nervous disturbances of menstruation, parturition, lacta- 
tion, and the climacteric period : (8) particularly exciting or exhausting 
employments, bad hygienic conditions, bad air, working in unventilated 
shops, mines, etc. ;' (9) the want of those normal and physiological brain 
stimuli that are demanded by almost all brains, such as amusements, 
social intercourse, and family life ; (10) a want of educational develop- 
ment of the faculty and power of self-control in childhood and youth ; 
(11) the occasion of the recurrences in alternating insanity, or the 
beginning of ordinary insanity ; being coincident in a few of these cases 
with the periods of depression, but mostly with the beginning of the 



STATES OF DEFECTIVE INHIBITION. 251 

periods of exaltation ; (12) the brain weakness resulting from senile 
degeneration. More than one of these causes may, and often do, exist in 
the same case. 

The neurine-stimulant craving is nearly always associated with 
impulses or weaknesses of control in other directions in by far the 
majority of the cases, while there may be no insane delusion. Yet all 
the faculties and powers that we call moral are gone, at all events for the 
time that the craving is on. The patients lie ; they have no sense of 
self-respect or honor ; they are mean and fawning ; they cannot resist 
temptation in any form ; they are erotic, especially at the beginning of 
an attack ; they will steal ; the affection for those formerly dearest is 
suspended ; they have no resolution, and no rudiments of conscience in 
any direction. The common objection to reckoning such persons among 
the really insane is that, though they have brains predisposed by heredity, 
they have often brought this condition on themselves by not exercising self- 
control at the period when they had the power to do so ; but this applies to 
many cases of ordinary insanity. Another reason is that, when deprived 
of their stimuli for a short time, they are sane enough in everything except 
resolution not to take to them again. The effect of the excessive use for 
a long period of nerve stimuli of all kinds is to diminish the controlling 
power of the brain in all directions, and to lower its highest qualities and 
finest points. The brain tissue is always so fine, so delicate, and so sub- 
tile-working, its functions are so inconceivably varied and so high, that 
under the most favorable circumstances it runs many risks of disturbances 
of its higher functions. But when we have a bad heredity, a bad educa- 
tion, and a continuous poisoning with any substance that disturbs its cir- 
culation and paralyzes its capillaries, that excites morbidly its cells, that 
proliferates its neuroglia, thickens its delicate membranes, and poisons its 
pure embedding lymphatic cerebro-spinal fluid, we cannot wonder that 
its functions become impaired and are not fully or readily resumed in all 
things. The unfortunate peculiarity is, that while we may restore the 
bodily and even the nervous tone so far as muscularity, sleep, and sensory 
functions are concerned, we have the utmost difficulty in restoring the 
higher functions of self-control and morals in some cases. A dipsomaniac 
when at his worst is readily recognized to be so really insane as to be in 
a fit state to be placed under the control of others for proper care. When 
he is at his best — after a few weeks' compulsory deprivation of his brain- 
poison — he is so like the rest of the world in all essential things that it is 
most difficult to see how laws can be framed in the present state of public 
feeling and medico-psychological knowledge to deprive him of his liberty. 
We cannot regard the drink-craving alone. We must be prepared to deal 
with the opium eater, insane smoker, chloral taker, gambler, and even 
many thieves and insane speculators. The state of brain in all these is 
the same in its essential nature. It would be inconsistent to provide 
against and try to cure the one Avithout including the others. 

I shall now show you a typical dipsomaniac F. B. His mother had 
been melancholic at one time, and her family was a neurotic and insane 
one. He was of a nervous temperament from the beginning: a flesh 
eater from a child; precocious and quiet, but not dogged in application; 
vain to an almost morbid extent, and in some points not endowed with 



252 STATES OF DEFECTIVE INHIBITION. 

common sense. At puberty he had a slight attack of chorea. About 
seventeen he showed keen social instincts, but no realization of the serious- 
ness of life. Especially the nisus generativus was periodically so strong 
as to be difficult of control, and he did not control it. Being a "jolly 
fellow," and mixing with such, he took alcoholic stimulants of all kinds 
very freely, and showed a very great fondness for them. He occasion- 
allv sot drunk. About twentv he was addicted to bouts of drinkino- and 
whoring, which came on periodically, and seemed to pass off and leave 
him fit for his work. He was ashamed of them afterwards, and I believe 
very often by his volition and self-control did not at this time indulge in 
them even when he craved them. At twenty-two he was very distinctly 
AYorse. He had less power of applying himself to anything. He took 
almost regularly recurring periodic bouts of drinking, during which the 
craving for alcohol was intense and quite irresistible. I have known him 
drink turpentine, eau-de Cologne, and chloroform when he could not get 
alcohol. He was nervous, tremulous, and unable for any kind of work 
while the fit lasted. He would lie, cheat, steal, and associate with the 
lowest characters at those times. When he recovered he was facile, 
lacking in conscientiousness, and somewhat unveracious, though a charm- 
ing companion. .All sorts of things were tried — long sea voyages, a 
colony, isolation in a doctor's family — but no permanent improvement 
was produced. He sank lower and lower mentally and morally, till at 
thirty he was really weak-minded and unfit for respectable people to asso- 
ciate with, and unable to do any work of any kind. !N^ot an atom of 
self-respect was left in him. He is now, at forty, in a mild state of de- 
mentia. 

That is one type of dipsomania. I have only known two such who 
recovered. Treatment is usually begun too late. In reality, youths 
with such a constitution of brain should live on milk and farinaceous food 
in childhood, should not be brought up in cities, should never touch al- 
cohol, should be trained in strictest morality and with little temj^tation, 
should marry early if possible if the drink-craving has not been awakened, 
and should not lead exciting, hard lives. After they have become dipso- 
maniacs, in the present state of the law that does not allow legal inter- 
ference with their liberty — I say it with deliberation — the sooner they 
drink themselves to death the better. They are a curse to all who have 
to do with them, a nuisance and a danger to society, and propagators of 
a bad breed. The essential texture and working of such brains are bad, 
just as much, but in a different way, as an ordinary insane man's. Such 
cases may be called dipsomaniacs by natural development. There is an 
essential weakness of mind underlying that sort of case. 

Here is another kind of case. E. C, a married woman ; the mother 
of a large family. She was quite well, and showed no drink-craving 
till she was thirty. When pregnant with her sixth child (the three pre- 
vious children having been all born and suckled within five years, all her 
labors being hard, and in one case with post-partum hemorrhage) she be- 
came quite suddenly changed mentally and morally. She got careless, 
slovenly, lazy, self-indulgent, neglectful of her children and family duties, 
evidently not so fond of her husband and children, irritable, and un- 
truthful. In addition to all this she took to smoking and drinking. 



STATES OF DEFECTIVE INHIBITION. 253 

This continued till three months after the birth of her child, when she 
became slightly depressed for two or three months, and was then quite 
well till next pregnancy. The same condition that I have described came 
on again. It has come on and gone oiF with a certain regularity fifteen 
years now. I expect it to cease at the climacteric period. She has had, 
by the way, two attacks of convulsions. This form of dipsomania I look 
on as one form of alternating insanity. 

Here is a third kind of case. F. D., an educated professional man, 
whose heredity I could not ascertain, who had worked very hard, and 
had been most successful; a man of power, of a nervous, enthusiastic 
temperament, and of great natural endurance and capacity for work. 
He took too little holiday, and unfortunately, from a mistaken idea of its 
real use, took to alcohol to restore his weariness, keep himself up to his 
work, and produce sleep. It seemed to do all those things at first. But 
he soon could not work or sleep without it, and it lost its power, so that 
he had to take more and more, and oftener and oftener. At last he got 
absolutely dependent on it, but it would not make him work enough. 
He took big doses, and had an attack of acute alcoholism. After this 
he pulled up, but only for a time, and he took to it again with the firmest 
resolve to restrict himself to small doses. In six months he was as bad 
as ever, and had several severe altoholic convulsions. This occurred 
again and again, and he became temporarily maniacal, with all the motor 
symptoms of alcoholism. He got better of this, took to drink again, and 
had convulsions, mania, and alcoholism. Morally he was weak, un- 
truthful, and unreliable, but never so bad as the youthfully developed 
dipsomaniac F. B. He died, after a few years, demented, and with par- 
tial paralysis of the diseased membranes and arteries and the softened 
degenerated brain neurine that usually follows the continuous excessive 
use of alcohol. 

That is a case of dipsomania caused simply by the excessive use of 
alcohol in an originally good sound brain. There is much hope in such 
cases if taken in time, if they can then be made to see the importance of 
absolutely abstaining from alcohol altogether. The continuous use of the 
bromide of potassium I have found most useful in such cases. It dimin- 
ishes the intensity of the craving, and lessens the excitability of the 
brain. Never in this nor any other class of insane drunkards think of 
tapering off the drink. Knock it off at once, and completely. I never 
saw any bad result from this. 

The moral treatment and management of dipsomaniacs is now one of 
the most unsatisfactory things a medical man has to undertake. The 
relations and friends of some patients will implore you to do something 
or recommend something; yet nothing can in most cases be done. Lu- 
natic asylums are certainly not the proper places for them, and when 
sent there they cannot be kept long enough to do them any good. What 
we want is an island where whiskey is unknown ; guardianship com- 
bining authority, firmness, attractiveness, and a high bracing moral tone ; 
work in the open air; a sim})le natural life; a return to mother earth 
and to nature ; a diet of fruits, vegetables, bread, milk, eggs, and fish : 
no opportunity for one case to corrupt another; and suitable pnnisluuents 
and deprivations for offences against the rules of life laid do^Yn — all this 



254 STATES OF DEFECTIVE INHIBITION. 

continued for several years in each case, and the legal power to send pa- 
tients to this Utopia for as long as medical authority determines, with or 
without their consent. That would be the ideal mode of treatment. In 
real life the best thing we can do is to send our cases to distant farms or 
manses, or doctors' houses in remote parts of the Highlands and Islands 
under a firm moral guardian. I am very sceptical about institutions for 
dipsomaniacs where many of them are together. In that case the moral 
atmosphere tends to be low, the patients keep each other in countenance, 
you cannot restore the sense of shame and of self-respect, and they plot 
and fan each other's discontent. If an ordinary dipsomaniac does not 
want to be cured, no power in heaven or earth will cure him. In that 
case, no law permitting forcible seclusion will do any permanent good in 
the way of cure. It is easy in many cases to produce a temporary 
amendment, to rouse a sense of shame and regret for the time being ; 
but what is the use of that when they return to the world, if there is no 
power of inhibition against the first glass, and when the first glass creates 
an irresistible craving for the second ? 

Kleptomania. — This interesting variety of uncontrollable impulse 
seldom exists alone without other morbid mental symptoms being present. 
The mere desire to appropriate for one's self what does not belong to one 
is an instinct strongly developed in the animal kingdom, in primitive and 
savage man, in children, and in many kinds of mental disease. Imbeciles 
appropriate and hide what they fancy, just as jackdaws do. The desire 
is there, and there is no inhibition. In general paralysis appropriation 
of all kinds of things is most common. I have now a j)atient who every 
day stufiPs his pockets with rags, stones, bits of glass, broken pottery, etc., 
till he looks as if he had a meal bag on each side of him. Every night 
his attendant throws these things away, but the process is repeated 
next day. I once found a general paralytic trying to stuff" the coal- 
scuttle into the backside of his trousers. Some demented patients steal 
everything they can lay their hands on. I have never myself met with 
a pure case of kleptomania without other mental symptoms. 

Pyromania. — A good deal has been written on the morbid tendency 
to set things on fire. There is no doubt that it exists, but there is more 
doubt about its existing alone without other symptoms of insanity. I 
now show you a marked example of the disease, combined with some 
melancholic depression of mind, and with one or two delusions. 

F. E., get. 59 on admission. The cause of her attack was mental 
distress at a sister's becoming insane and dying in the asylum. She was 
melancholic and suicidal on admission, and had delusions that she had 
been guilty of great crimes. A first she tried to commit suicide by tying 
pieces of cloth round her neck to choke herself with. In six months her 
mental condition assumed the form of an intense desire to set things on 
fire, to set her clothes on fire, to burn the house. She became impul- 
sively violent at times. She set fire to her hair one day, another day 
rushed into a dormitory, shut the attendant out, shovelled the live coals 
from the fire on to a mattress, threw herself among the burning mass, 
and pulled another mattress on the top of her, severely burning herself, 
and, in fact, nearly losing her life. She sits saying to herself, " I maun 
mak them low" (I must set them on fire), day by day. In four years 



STATES OF DEFECTIVE INHIBITION. 255 

this impulse to burn became less intense, and she was more enfeebled in 
mind, and in about six years after admission she was thought to have got 
quite over it; but one night she went into a dormitory and set all the 
bedding on fire from a gas-jet, but did not attempt to burn herself or her 
■clothes. Now, at the end of nine years, she is demented, but still has 
the remains of the old impulse, though in a very slight degree indeed. 

I was once asked to see a man called J. F. Wilson, who was in the 
Edinburgh gaol on a charge of fire-raising, having at two places set fire 
to stackyards. I found that he had once undergone punishment for a 
similar ofifence, and that on being taken up on this occasion, when going 
with the police sergeant to the station, he remarked on passing a big 
haystack: "That would make a fine blaze." I found him to be a case 
really of delusional insanity with a good deal of general enfeeblement of 
mind and hallucinations, hearing voices telling him to commit rape, and 
the voices and screams of old friends often in the night. In addition to 
a desire to set things on fire, the sight of which gave him pleasure, a 
female he had once known often said to him, when he was thinking of 
doing so, "If you are to do so, do it quickly." I considered the causes 
of his disease to have been heredity, drinking, and syphilis. He had 
suffered from one attack of mania, for which he had been in Colney 
Hatch Asylum. I did not think hie had any chance of recovery. He 
was found insane, and sent to the lunatic department of Perth Prison, 
but was discharged recovered. Within a few months he again set some 
stacks on fire. This time I could discover no symptoms of insanity about 
him, but a slight general mental enfeeblement, and he received sentence 
as an ordinary criminal. 

The majority of the cases where an impulse to set things on fire is the 
chief symptom of mental impulse have been young persons about the age 
of puberty and adolescence, of strong nervous heredity. In such patients 
it is merely another manifestation of that morbid impulsiveness and "in- 
stinctive" action, of which the homicidal impulse that I have described 
is the most marked example. 

Moral Insanity. — The morals and affections are lost or become 
altered in many forms of insanity. The question is — Have we any 
examples where, from disease, a man who had up to that time been 
moral and conscientious, and obeyed in his conduct the laws and the 
social observances, had lost his moral sense while he retained his intelli- 
gence and reasoning power, having no mental exaltation or depression, 
and in consequence of that diseased moral condition, spoke and acted 
immorally? Further comes the question — Can he, when the diseased 
condition is cured or recovered from, regain his former morality in feeling 
and conduct? I have no hesitation whatever in answering both questions 
affirmatively, because I have seen such cases. It is not a (]uestion of 
theory, but of fact. A tliird question arises — Do we meet with children 
so constituted that they cannot be educated in morality on account of an 
innate brain deficiency, rendering them incapable of knowing the differ- 
ence between right and wrong, of following the one and avoiding the 
other, of practising checks on inclination, of exercising self-control or 
obedience to the laws of God and man, of any love and cultivation of the 
good, or any dislike of evil ? Such uioral idiots I, like others, have met 



256 STATES OF DEFECTIVE INHIBITION". 

with frequently. Persons with this disease, and persons with this want 
of development, we say labor under moral insanity. 

Conscientiousness, the sense of right and wrong, is, to a large extent, 
an innate brain quality. We see this in children from the earliest age. 
Some have it strongly, without teaching or example; others have it spar- 
ingly, and need the most assiduous care to develop it. I have referred 
to a morbid conscientiousness that is sometimes seen at early ages in 
children, and in some of them is followed by a paralysis of the sense at 
later periods of life. I was once consulted about a boy (F. H.) of ten, 
not an idiot or an imbecile, and quick intellectually, who could not be 
taught morality. He really seemed incapable of knowing the difference 
between a lie and the truth, or, at all events, he never could be got to 
avoid the one and tell the other. And he lied without any temptation, 
and with no object to be gained. His statements as to the most ordinary 
matters of fact were never believed, merely because he made them. He 
stole; he had little proper affection for his brothers and sisters and 
parents; he was incapable of the sense of shame. When punished or 
scolded he became mentally paralyzed and in a condition of stupor, in- 
capable of knowing or doing anything whatever. As this boy approached 
puberty he developed some moral sense. His grandmother had been 
insane. I knew a boy, F. I., one of a very neurotic family. Grand- 
mother insane, father a dipsomaniac, and two sisters melancholies, and 
other two with various neuroses, who was untruthful and immoral instinc- 
tively. No one who knew him ever believed a word he said. He stole, 
he had small affective power, and he never seemed to see why anybody 
should be offended at acts of immorality or dishonor. He was carefully 
and religiously brought up. In after-life he turned out a selfish and 
negatively immoral man. He never paid any debt that he could help, 
and he borrowed from everyone he could. He treated his relations badly. 
He on several occasions did public acts that might have brought him 
under the cognizance of the criminal law. He did these things in a 
stupid way, as if he himself was quite unconscious he was doing wrong. 
Such cases are the bane and disgrace of their friends and families, and 
the skeletons in the closets of their relations. Nothing can be made of 
most of them morally, any more than a genetous idiot can be converted 
into an active-minded man. Wrong is right to them: they prefer lies to 
truth, immorality to morality. I knew one such case (F. K.) who was 
continually breaking every commandment of the decalogue. He went 
through a form of marriage with four women, to each of the last three 
having told that he was unmarried, and I just saved the fifth by a few 
hours from going through a form of marriage with him ! Several members 
of his family had been insane, and others subject to various neuroses. 
He took his heredity out in immorality. 

The occurrence of moral insanity as a disease in those who have pre- 
viously had the moral sense, and have exercised self-control, without at 
the same time the presence of morbid mental exaltation of some sort, is 
not in experience so common as the want of a moral sense from con- 
genital deficiency. Pritchard quoted many such cases, and vividly de- 
scribed the disease, but I should place most of his cases in my category 
of simple mania, like C. B., C. C, and C. F. (pp. 128, 131, 133). 



THE INSANE DIATHESIS. 257 

There was distinct mental exaltation along with the loss of moral sense. 
But in the following case there was no apparent exaltation : 

F. L., set. 37, a lady of mixed race, her father having been English 
and her mother of a distinguished Hindustani family. Up to the age of 
thirty she had been as other women, had married, borne children, and 
conducted her affairs discreetly under many difficulties. About that time 
she entirely changed, morally and affectively, without intellectual per- 
version and without mental elevation or depression. She went to a 
distant part of the country, where she was not known, got acquainted 
with various persons there, especially fascinating one poor gentleman of 
a benevolent disposition. She said she was the heiress to vast estates and 
to a title. Through this gentleman she got introduced to other persons, 
some of whom believed her impossible stories. She carried out impos- 
tures most daringly and cleverly. She got introduced, or introduced 
herself, to one great nobleman after another. She imposed on the 
Secretary of State for India by sheer impudence and lies. She went to 
a public meeting where she knew a nobleman of philanthropic zeal was 
to speak, told the doorkeeper she was an intimate friend of his, and was 
shown into the private room reserved for him ; told him when he arrived 
that it was she who was the great support of the movement about which 
he was to speak in the district, was taken and seated by him on the 
platform, and so got introduced to many other distinguished persons. 
She raised large sums of money, amounting altogether to many thousands 
of pounds, on no security whatever. She furnished many houses most 
extravagantly at the expense of trusting upholsterers, and she got posses- 
sion of jewellery to a large amount. To one person she was a great 
literary character (and she did have printed, at other people's expense, 
a volume of other people's poems as her own), to another she was of royal 
descent, to another she had immense expectations, to another she was a 
stern religionist. All this was the prelude to an attack of hysteria, brain 
softening, and spinal disease, of which she died in a year, demented and 
paralyzed. And one of the most astounding things was that her first 
benevolent patron believed in her to the last, came to see her in the 
asylum, and was going to write her biography as that of the most won- 
derful woman he had ever come across — this being a decent middle-class 
man, who by his honest industry had made a small fortune, and had lost 
.£8000 of it through her. And he was counted sane and she insane ! 



THE INSANE DIATHESIS. 

A description of the general symptomatological forms of mental dis- 
orders would not be complete without reference to a condition of mentali- 
zation which has been called the insane diathesis. Maudsley, in this 
country, and Morel, in France, have described it better than any other 
authors. The great difficulty about its description is that we find few 
cases of this condition alike, and its special manifestations in diilerent 
cases are as multiform as the human faculties, and as complex as different 
combinations of unusual developments of those faculties can make it. 
There are certain human beings characterized through life by striking 

17 



258 THE INSANE DIATHESIS. 

peculiarities, eccentricities, originalities in useless ways, oddities, dispro- 
portionate developments, and nonconformities to rule, these things not 
amounting to mental disease in any correct sense, and yet being usually 
by heredity closely allied to it, or by evolution ending in it at last. The 
children of insane parents, or some of the members of families who have 
developed many neuroses, are most apt to exhibit the symptoms of the 
insane diathesis. Its symptoms are so various that they cannot be briefly 
described. One has merely to read the works of the modern psycho- 
logical novelist to find the type of person I refer to in abundance. No 
one has lived long in the world without meeting in the flesh many 
examples of it. 

And there have been enough examples of it in the real lives recorded 
in biographies, ranging from the inspired idiots to the inspired geniuses 
among mankind. We may safely reckon Chatterton, De Quincy, Cowper, 
Turner, Tasso, Lamb, and Goldsmith, to take a few men of genius, as 
having had in some degree the insane temperament. We find some such 
persons strikingly original, but not reasonable ; different from other men 
in their motives, in their likings, in their ways of thinking and acting to 
such an extent that human society would at once come to an end were all 
others like any of them. They are all in the highest degree "impracti- 
cable" and "unwise" in the conventional senses of those words. Some 
are abnormally sensitive and receptive, others abnormally reactive. Some 
are subject to influences and motives that are absolutely unfelt by ordi- 
nary men, such as hypnotism, sympathy with animals, etc. Most of the 
spiritualists, thought-readers, and clairvoyants who are honest, as well as 
many "Bohemians," are of this class. The actions of most of them may 
be described as instinctive. They do not find their way to lunatic 
asylums, but their friends often have to consult our profession about 
them, especially in youth. And fortunate would it be for many of them 
if the doctor had the direction of their upbringing on physiological and 
medico-psychological principles, instead of the schoolmaster on doctrinaire 
and purely mental ideas. How much unhappiness might have been saved 
in the world had this been done! For if there is any distinguishing 
feature of many of them, it is the capacity to be miserable. Nothing 
reconciles one so to the abundance of commonplaceness and stupidity in 
the world as a study of the lives of some of these persons. And surely 
our profession will in the future be able to apply its knowledge of brain 
function and development and the laws of heredity towards making the 
most of such lives, strengthening the weak points without forcing down 
the strong ones, saving from misery and ruin without depriving humanity 
of their originality and intenseness. I have one case in the asylum that 
may be counted as of the insane temperament. F. M., the son of an 
eccentric fether, who could not get on as a student, because he would 
insist on studying, not what was prescribed, but what he liked, whose 
knowledge is prodigious on all subjects — the only man whom I ever knew 
who had read through the JEncijdopoedia Britannica^ and lived — but 
whose common sense is infinitesimal. I never saw any man, sane or 
insane, who could "make such a fool of himself," in an ordinary com- 
pany of ladies and gentlemen. He has most original ideas as to the 
future politics of Europe, founded on a profound study of the mental 



THE INSANE DIATHESIS. 259 

characteristics and capacities of the races who inhabit it. Yet he will 
get up and sing "Mj Pretty Jane" in a large company, out of tune and 
out of time, and so ridiculously that there is scarcely a dement in the 
asylum who will not laugh at him, and call him ''daft." He is totally 
unfitted to "get on" in the world in any way. I presume it was this 
that drove his friends, after many trials elsewhere, to send him to a 
lunatic asylum, as the only place fitted to receive such a being. 

Do not suppose for a moment that all persons of the insane diathesis 
are geniuses or talented. Nothing could be further from the truth. 
Most of them are, on the contrary, very poor creatures indeed, a nuis- 
ance to their friends, and no good to the world at large. 

The insane diathesis differs essentially from the German Primare 
Verrilehtheit. The latter is an insanity naturally evolved in early life 
from the original constitution of a brain which may have been at first 
without peculiarity, but gradually, inevitably, and without any other 
cause than its own natural evolution, an unsound state of mind is de- 
veloped without preliminary explosion of brain-storm in the shape of an 
attack of mania or melancholia. 



LECTURE X. 

GENEKAL PAKALYSIS— PAEALYTIC INSANITY. 

General Paralysis is not only a variety of insanity, but a true cere- 
bral disease, as distinct from any other disease as smallpox is from scar- 
latina. It is a disease of extraordinary interest physiologically, patho- 
logically, and psychologically. Its study has somatized and definitized 
the study of all mental diseases, and has added, and will add still more, 
to our knowledge of the connection of mind with body, and of mental 
and motor disturbances. What we knew of its symptoms and pathology 
ought to have led to the conclusion that the cerebral convolutions have 
motor functions long before Hughlings Jackson, Hitzig, and Ferrier ar- 
rived at their generalizations on the subject. Being a distinct disease, 
clinically and pathologically, it can be defined, and I should give its defi- 
nition thus : A disease of the cortical part of the brain, characterized 
by progression, by the combined presence of mental and motor symptoms, 
the former always including mental enfeeblement and mental facility, 
and often delusions of grandeur and ideas of morbid expansion or self- 
satisfaction ; the motor deficiencies always including a peculiar defective 
articulation of words, and always passing through the stages of fibrillar 
convulsion, incoordination, paresis, and paralysis ; the diseased process 
spreading to the whole of the nerve tissues in the body ; being as yet in- 
curable, and fatal in a few years. 

The disease, for convenience sake, has been divided into three stages, 
the first of which is that of fibrillar tremblings and slight incoordination 
of the muscles of speech and facial expression, and of mental exaltation 
with excitement ; the second that of muscular incoordination and paresis 
with mental enfeeblement ; and the third that of advanced paresis, or no 
power of progression, almost inarticulate speech, and at last paralysis 
with mental extinction. Those stages form a convenient basis for the 
study of the disease. 

Let us look at a case in the first stage of the disease. 

F. Y., a fine, strong, handsome man of thirty-five, without any known 
hereditary predisposition to insanity, who had enjoyed good health up to 
the time of his present attack. His temperament is sanguine, diathesis 
neuro-arthritic, and his disposition frank, unsuspicious, boastful, and 
hasty. He always had a high opinion of himself, and showed it ; was 
of an imaginative turn, and had a physiological tendency to exaggera- 
tion. His feeling of bien etre was always above the average; his habits 
had been industrious, and at times he had worked very hard indeed. He 
had not been dissipated in the worse sense, but he had lived freely, taking 
lots of alcoholic stimulants habitually, eating much, sleeping generally 
too little, and, above all, exceeding greatly in regard to sexual intercourse, 



GENERAL PARALYSIS. 261 

both before his marriage and since — he had been married for three years. 
He had never had syphilis that I could make out, and certainly has no 
evidence of the disease on his body. For a few months his friends have 
noticed that he "has not been the same." Six months ago he was "not 
in good spirits," and complained of flying pains in ,the head; then he 
was a little forgetful, wanting in application to his work, restless, doing 
some "unaccountable things" in business, e. g., forgetting to claim 
money due to him. He was irritable at home, a thing unusual with him. 
A month ago he began to express an exaggerated sense of well-being, 
saying he never was so well in his life, that his strength was "something 
wonderful; " he could not settle down to his daily work, his natural high 
opinion of himself was more openly expressed to comparative strangers, 
one of whom remarked after seeing him, "what a conceited fool that man 
is." This state went on without any other absolute signs of insanity, 
and without awakening the suspicions of his friends that he was mentally 
wrong — that is always about the last thing thought of — until one morning 
he announced to his wife that he had the day before purchased several 
hundred pounds' worth of silver plate, and had ordered his coat of arms, 
with his name in full to be engraved on each article. He added that he 
had lots of money, and had a schenje through which in a week he would 
be worth many hundreds of thousands of pounds. On inquiry it was 
found that he had ordered the plate ; but the jeweller, being a man of 
sense and principle, having noticed some little thing in his manner that 
savored of morbidness, had not taken any steps to execute the order till 
he made some inquiries. Many commencing general paralytics are not 
so lucky as this. I knew one who spent <£1000 that had taken him ten 
years to make in a week before his disease was discovered, and another 
who spent .£7000 in a month. F. Y.'s wife found that he had been 
buying a quantity of perfectly useless things in addition to the plate, 
some of them in duplicate. He had in his pocket four gold pencil-cases, 
which he said he was to give away as presents to people to whom he was 
under no obligation, and did not know very well. She of course saw 
that something was wrong, and he was got oif to the country. The 
restlessness by night and day increased ; there was constant talking, 
almost complete sleeplessness ; the boastfulness became in three or four 
days exaggerated delusions. He said he could lift one thousand pounds, 
that he was the best rider, swimmer, and jumper in the world ; he 
wanted to buy every farmer's horse he met on the road, never offering- 
less than .£100 for any animal, and at once bidding another £100 if the 
first offer was jocularly refused. He wrote quantities of letters to all liis 
friends, to all the noblemen in the district, and to the Queen, offering liis 
services to make their fortunes, and asking them to dinner. The only 
visible peculiarity of the writing was the omission of many single words. 
In a few days more he was maniacal, and so impatient of contradiction 
that he struck his wife, though tlirough all tliis he was in many respects 
fiicile and easily managed. He therefore had to be brought to the asylum 
a week ago. When he saw me he offered to buy the institution for 
£100,000, and, on my saying that Avas too little, offered £-200,000, and 
soon got up to £1,000,000. On my saying that we could not want it, 
he said he would build another, the most maoniiicent in the world, and 



262 GENERAL PARALYSIS. 

endow it with a million a year, and appoint me physician-in-chief with a 
salary of c£10,000, first getting the Queen to create me a baronet and 
giving me a splendid uniform, chiefly made of gold cloth. He has been 
sleepless, destructive to his clothing, not cleanly in his habits or modes 
of eating, in constant motion, facile in most respects, but irritable and 
impulsively violent when his commands were not instantly obeyed, or 
when he was prevented from carrying out his grand schemes. He 
expressed no surprise at being brought here at all, and no resentment at 
those who brought him. 

Look at him now. He came into the room with a quick step. His 
attitudes and gestures follow and accentuate his speech. He talks rather 
quickly, and has the least slurring towards the end of long sentences and 
in articulating long and dijBficult words with many oft-repeated consonants. 
"Round about the rugged rock the ragged rascal ran" was got through 
fairly well the first time, but at the second attempt the ''ragged rascal" 
got into a sort of inarticulate slur. This is accompanied by fibrillar 
twitching in the small muscles of the lips and round the eyes, as if a 
sudden electric current had set these quivering. As he breaks into a 
smile this is very apt to happen. His tongue quivers in lines on its 
surface, single strands of muscle being affected. His pupils are contracted, 
irregular in outline, and the right is distinctly larger than the left, the 
latter being quite insensitive to light. Sometimes it is one pupil and 
sometimes the other that is small and insensitive, or large and insensitive, 
in different cases. The expression of his eyes is feverish and strange. 
His skin is moist, and feels hot. His temperature is 99.6°, this rising to 
over 100° at night; his pulse is full and hard. He cannot rest or sit still. 
There is clearly an abnormal generation of energy in his motor batteries. 
When we test his common sensation, it is found to be markedly dimin- 
ished. His sense of smell is weakened, though it is not, as Voisin says, 
so blunted that he cannot smell pepper. I have seen only a few cases 
where smell was so ansesthetic as this. He tastes, though a little imper- 
fectly ; by and by he will not be able to distinguish a solution of quinine 
from milk. Shown a lot of colored wools, he could not tell the blue, 
calling it red. His patellar tendon reflex is very acute, and also the 
spinal and skin reflexes. You noticed how easily he was led off from 
one subject to another ; this facility is one of the most characteristic 
of all the symptoms present in all stages of the disease. But he is 
irritable on contradiction, and resents thwarting, especially if it is done 
suddenly and imperiously. General paralytics at this stage are some- 
times most dangerous from their absolute fearlessness of consequences. 
This insane boldness gives much trouble. An ordinary insane patient, 
if not deliriously maniacal, will usually yield to the show of force, but a 
general paralytic will try to fight and resist any number of men. When 
we try him to walk along a board of the floor, he does so sprightly and 
well, but on telling him suddenly to turn round, he cannot do so 
sharply, but takes a circle, and that waveringly. 

This man is in the first stage of his disease. He will steadily grow 
worse, losing body-weight rapidly, his speech getting worse, more tremu- 
lous, and having more difficulty in articulating long words and sentences. 
His motor excitement will be shown probably by his tearing dozens of 



GENEEAL PARALYSIS. 263 

suits of clothes all to ribbons. I have a gentleman who tore one great- 
coat into over a hundred pieces, saying — "I'm g-g-going to put it 
tog-g-ger again as soon as I g-g-get to Jeru-sh-lem. I've got a million 
coats there." His walking will become affected, and his mental power 
will become gradually more enfeebled. He will believe all the delusions 
of his fellow-patients. A general paralytic is about the only insane 
person, except a congenital imbecile, who cannot see that some of his 
fellow-patients in an asylum are insane. Their letters are usually 
characteristic. Here is one : 

"The . . . 1 of the Millenium. K. E. A. "When I reach the elect, teleght. office 
will send a despatch the Times Millenum begins. Yours in the Holy love of 

God and the Holy Trinity, Israel Jesu Christ." 

Here is another, addressed ''Countess of Elgin and Durham," but 
really to the Queen : 

" House, Koyal National Lunatic Asylum. 

" My Dear Wife, — I am very glad to say that I am up to the mark in every 
particular, and hope your system is up to the scratch. Has John Brown undergone 
any form of cremation? I am glad to . . . him adopting my style of shepherd 
checked trousers. I hope both Queens are well, with Princess Louise, Princess 
Beatrice . . . that I will give them all that is necessary in this world and the world 
to come. Compts. to darling ' Eugene ^ — Your affiit. husband." 

The nisus generativus is usually not exalted in general paralytics. In 
fact, impotence is the rule during the latter end of the first stage, and 
even after. I have, however, known cases where children were pro- 
created in the beginning of the first stage, and I have one case now who 
was impotent for over a year in the first stage, but whose sexual power 
returned in the second stage, with many other apparent signs of improve- 
ment, and his wife had a child to him, begotten then. He again became 
impotent in the end of the second stage. I have known more than one 
case of general paralysis who was a masturbator during the early part of 
the first stage. 

Let us now see a typical case in the second stage of the disease. 

F. X., now forty-five, a clerk, with a history somewhat resembling 
F. Y. He became affected a year ago, and has passed through a first 
stage of exaltation and excitement, which for the past two months has 
been slowly passing off. Mark his facial expression, or, I should rather 
say, his want of facial expression. His face looks fat, heavy, and dull, 
as if the expression had been wiped out of it, and this even when he 
speaks. There are no movements of the features corresponding with the 
emotions he is experiencing. There is a heavy flabbiness about him. 
After losing oyer two stones in the first stage of the disease, be has now 
made it up again in fixt if not in muscle. 

There is a contented facile hebetude of mind in him. He expresses few 
wants, says he is quite Avell, and that he can walk, work, sing, or do 
business as well as he ever did, none of which is true, for lie is very 
shaky on his legs, cannot walk a mile, his handwriting is tremulous, and 
he has no initiative mental powci', no spontaneity, and no power of voli- 

* Where Avords are oniittinl. 



264 GENERAL PARALYSIS. 

tion. He does not now obtrude his delusions, but when asked he still 
says in a silly way he is rich and strong, but hesitates to specify the 
millions he is worth, until pressed. He agrees with all you say, and is 
facile and easily managed. His pupils are widely dilated, and the left 
more so than the right : his pulse is 68, and easily compressible ; his 
temperature 97°, but still a little higher at night; his tendon reflex is 
dull ; his spinal reflex function dull too ; his power of swallowing a little 
impaired. His speech is most markedly afiected now, and the tone of 
his voice is quite changed. He cannot say " round about the rugged 
rock the ragged rascal ran " at all. There are still some tremblings 
about his face as he speaks, but they consist of the incoordination of 
-whole groups of facial and articulatory muscles. He is very kleptoma- 
niacal, picking up and stuffing into his pockets any bit of trash he can 
lay hands on. The dorsum of his tongue presents a general undulatory 
surface when put out. He cannot turn round quickly without risk of 
falling : he straddles a little in walking, is apt to stumble over small 
obstacles, and the efi"ort of a long walk so exhausts the energizing power 
of his motor batteries that he gets almost paralyzed, and is then unable 
to walk at all. There is no vigor in any muscular movement he per- 
forms. His urine often dribbles away. Occasionally he is noisy at night 
in an automatic, causeless way. He will become weaker steadily. His 
speech will soon become less articulate, until he reaches the third stage, 
ivhich this next patient has reached. 

F. W., set. 40. Has had general paralysis for two years, and has 
passed through the first and second stages. He is now so paralyzed that 
he cannot walk or even stand steadily. He cannot write, and his mental 
state is that of a happy lethargy. TMien asked if he has a million of 
money his facial muscles begin to act in an incoordinated way, his eye- 
lids half shutting, his mouth being drawn out, the lips moving spasmodi- 
cally like a patient going into an epileptic fit, the whole efiect being that 
of a contorted imitation of a smile, accompanied by a slow, prolonged, and 
jerky "Y-a-a-a" — which is all that he can articulate for ''Yes." But 
he looks as if his subjective condition was one of perfect happiness. He 
asks for nothing, he complains of nothing ; he is noisy at night often, but 
it is in an automatic way. He needs to sleep on a mattress on the floor 
in a room specially warmed by hot air, for he rolls about the room at 
night. He is quite unable to retain his virine and feces by night or day. 
All his food has to be liquid or minced, for he would bolt it in solid 
masses and choke. He is greedy for his food when it is put into his 
mouth, though he is unable to feed himself. This man had two ''conges- 
tive attacks" to which most general paralytics are subject. One 
occurred about the end of the first stage of the disease, and was accom- 
panied by unconsciousness, a temperature of 103°, general convulsions 
which began and ended on the right side, but afiected the whole body in 
the middle of the attack. They lasted for about four hours, and were 
succeeded by stupor, which lasted for forty-eight hours. He had reten- 
tion of urine during that time, as he slowly recovered consciousness ; after 
that it was found that his speech and his walking were more paretic, and 
his mental power more enfeebled. Congestive attacks always leave the 
patients worse in these respects. The second attack was of the same 



GENERAL PARALYSIS. 265 

character, but less severe, and occurred in the second stage. Soon after 
it a fellow-patient struck him on the side of the head, and the ear of 
that side began to swell in the centre of the helix, this swelling slowly 
increasing in size until the ear was painted with blistering fluid, as rec- 
ommended by Dr. Hearder, when it ceased to increase in size, and 
slowly shrank up, leaving that part of the ear hard aiid slightly shrivelled. 
If it had not been blistered, the swelling would have increased until the 
whole ear would have looked like a bluish egg attached to the side of 
the head. This would have been found to consist of a bloody gelatinous 
material if it had been opened (but this should not be done), separating 
the outside skin of the ear from the cartilage. In time it w^ould have 
shrunk up, leaving the outside ear a hard, shrivelled, cartilaginous-looking, 
ill-shapen mass. This is the " insane ear," or hoematoma auris^ which is 
very common in general paralysis, and is sometimes seen in bad cases of 
mania of the chronic variety, sometimes in chronic epileptics, and occa- 
sionally in agitated and convulsive melancholia, and rarely in dementia. 
Its occurrence is always a bad sign for prognosis in any case of insanity. 
I have seen only three cases recover out of over eighty cases who 
had hoematoma auris. It is connected with arterial degeneration in the 
branches of the carotid artery. The gelatinous bloody contents of a 
haematoma are like the extravasations under the dura mater in pacJiyme- 
ningitis Jioemorrhagica inteima, a disease that is liable to occur in precisely 
the same class of cases. Hoematoma aims has been found in persons 
sane in mind, though very rarely. The exciting cause is often severe 
violence to the ear, but this is not necessary, and no violence will cause 
such a condition of the ear where the morbid arterial conditions for 
its formation do not exist. Blistering, if applied in time, usually stops 
further growth, but I have met with cases where it began to grow after 
being stopped, was again blistered, again ceased to grow, then again 
enlarged, and finally swelled up to the size of an egg in spite of blistering. 

F. Ws. common sensibility is much impaired, so that you can stick 
pins into him without his feeling it. The reflex action of his cord 
is over-acute, and extends upwards from the section of cord irritated, for 
if you tickle one foot they are both drawn up with a jerk, and the two 
hands and the chest muscles are contracted likewise. The impression 
travels upwards more readily than downwards. 

He will soon become so paralyzed that voluntary motion in the legs of 
any kind will cease. He will have to be placed on a water mattress, and 
his trophic power will become so affected that his urine will irritate his 
skin and bed-sores will tend to form, and he Avill die of exhaustion 
probably witliin six months from this time, or within three years from the 
beginning of his disease. 

Variations from the Typical Form. — The usual course of this 
disease is well illustrated by these three patients, but a large number of 
the cases do not follow the typical course. For the diagnosis of those 
exceptional cases we require first to know clinically the varieties tliat are 
found, to understand and take into account the true pathological nature 
of the disease, and to be ahle to separate the essential from the non- 
essential features of it. I shall instance a few varieties of the disease. 
The chief of these is where the pathological process does not begin in 



266 GENERAL PARALYSIS. 

the cortex of the brain, but in the cord (the tabic form) or in the neurine 
portions of the organs of special sense (the sensory form), or in a 
peripheral nerve (the peripheral form), spreading upwards by a patho- 
logical propagation along the connecting nerves in the lines of physiological 
function, till it reaches the brain cortex. These varieties are rare, but 
distinct enough when they occur, and very interesting. They would 
seem to imply that the pathological process of general paralysis is essen- 
tially the same as the progressive Wallerian atrophy of the nerve trunks, 
or the degeneration of the posterior columns of the cord in locomotor 
ataxia. I am not quite prepared to accept this conclusion, for there are 
as yet many pathological differences between the appearances of both of 
these and the brain cortex as affected by general paralysis. The essen- 
tial structure and the functions of the brain cortex are so different from 
any other portion of the nervous system that it is quite possible to 
suppose a diseased process of one pathological nature slowly advancing 
along a peripheral nerve or along the cord, and when it reaches the 
totally different and higher structure of the brain cortex, that it should 
assume a different nature, just as the process of gelatinous swelling of 
the synovial membrane of a joint when it reaches the cartilage, changes 
its pathological form, and becomes ulceration. And then it must be 
remembered that in those rare cases of what appear to be pathological 
propagation, there may have been the ordinary causes of general paralysis 
operating in regard to the cortex, and the peripheral disease may have 
been merely an extra cause at work. To show what I mean I shall refer 
to a few cases. 

G. A., a man of 50, who had been affected with ordinary typical 
locomotor ataxia for seven years, began to be maniacal and sleepless, and 
to have delusions of grandeur, affirming he was an earl and possessed 
millions of money, and that he could ride, run, and swim better than any 
man in the world. He used to write about fifty letters a day, ordering 
every sort of thing imaginable, asking the Queen, the House of Lords, 
and the Cabinet to dinner, etc. His speech was markedly affected by 
the characteristic tremble of the lips, the shuffle and thickness in the 
articulation of long words and sentences. He passed through the second 
and third stages of the disease, and died in eighteen months from the 
time of the beginning of the mental symptoms. There was no post- 
mortem examination in that case, but I have examined the brain and 
cord in other similar cases, and have found that the spinal disease could 
be traced up through the medulla and the lower ganglia into the brain 
cortex. I have always found in those tabic cases that the peculiar 
adhesion of the pia mater to the convolutions (see Plate I., Frontispiece) 
was more marked at the base of the brain and in the cerebellum instead 
of over the vertex, as in the typical case of general paralysis. In one 
such case, who died at Morningside Asylum, my late assistant. Dr. J. 
J. Brown, found the cord degenerated, not only in its posterior columns, 
but most markedly also in the anterior columns. In that case the medulla 
oblongata was more diseased than I ever saw in any other case of any 
kind. Not a single nerve fibre or cell seemed to be normal. 

The next case is the most typical of six cases I have met with, where 



GENEEAL PARALYSIS. 267 

there was first disease of the retina, and then, after some years, general 
paralysis. 

G. B., having exposed his head to a hot sun while bathing, had 
hemorrhage into the retina, causing complete blindness. After a few 
years he fell into general paralysis, and when he died I found that the 
optic nerves were hard gray cords, with no nerve substance left, that the 
optic tracts were in the same condition, and the gray sclerotic degenera- 
tion could be traced backwards to the corpora quadrigemina, the pos- 
terior of which were gray and sclerotic. The evidences of cortical 
disease were strongest at the base of the brain, the convolutions of the 
anterior lobes over the orbital plates being especially affected, the pia 
mater being universally adherent there. 

I knew a gentleman who became stone deaf in one ear several years 
before he developed general paralysis, and though I had no pathological 
proof that the case was one of propagation, I had no doubt in my own 
mind on the subject. He was a medical man, and his deafness was of a 
peculiar character, so that it alarmed him very much ; and when the 
first symptoms of general brain disease appeared, he said he thought it 
was just the extension of the disease from his internal ear. Professor 
Lay cock used to quote a case of his where the disease had spread upwards 
from a Wallerian atrophy of one of the motor nerves of one of the 
fingers. I had a case, G. D., a woman of thirty-six, who passed gradu- 
ally into an attack of quiet, non-delusional general paralysis after a small 
punctured wound in the top of her head penetrating for about half an 
inch into the brain. A pitchfork had fallen accidentally on the top of her 
head, as she was loading a cart of wheat. After death the whole of the 
convolutions round the wound were found specially affected, though the 
cortex in most parts of the vertex and sides of the brain were affected 
as well. 

There are many cases of general paralysis where the course, and even 
the nature, of the symptoms yary, within limits, very much from the 
typical symptoms and the typical course. They constitute symptomato- 
logical varieties of the disease. The most common and the most marked 
of these is the non-delusional variety, as seen in the following case, 
where there was no excitement, no delusions of grandeur, and no conges- 
tive attacks, but simply a gradual mental enfeeblement beginning with 
the volitional power, and a gradual paresis beginning with muscular 
weakness and fibrillar tremblings in the facial muscles and tongue, this 
gradually passing into complete incoordination. 

0. C, set. 50. A quiet-living man, who had married about three 
years before he became affected in mind, first showed mental defect by 
irresolution, want of a keen interest in anything, forgetfulness, and the 
want of a realizing sense of the necessity of his working in order to live. 
Soon he got a little irritable when pressed to work. Then his mind 
showed clears signs of enfeeblement and facility. He would believe 
silly things, he could not carry on a connected conversation, ho had few 
likes or dislikes. I saw him at this stage, and found his speech thick, 
his lips showing, as he began to speak, that fatal quiver wliich to a 
practised eye almost marks the disease from all others. His walk, too, 
was not firm, and in turning round sharply he did so uncertainly. He 



268 GENERAL PARALYSIS. 

gradually got more enfeebled and frail in mind, his speech became less 
articulate, and his walk more paretic. Nearly all his symptoms were 
negative. About the only positive mental symptom he had was a gentle 
kleptomania. He would pick up and fill his pockets with stray pocket- 
handkerchiefs, aprons, and rags in a sort of automatic way, not in the 
least caring or objecting when they were taken from him. He died in 
six years, absolutely paralyzed, of pure exhaustion, never having made 
a sound that could be called articulate for a year, or voluntarily moved 
a voluntary muscle during that time, lying on a water-bed, and leading 
a merely vegetative life. Such cases are apt to live a long time. They 
are not usually caused by a dissipated or excited life, and their subjects 
were originally of a calm, phlegmatic temperament. Nearly one-third 
of all the cases of the disease that I have seen were of this character. 
This type is very common in the female sex ; in fact, the majority of 
female cases conform to it more or less. It is also the common type of 
the disease in those parts of the country where the people live unex- 
citing lives. 

Standing at the opposite point from this quiet form of the disease are 
the two varieties of which I shall now give examples. The first is the 
specially convulsive form, as exhibited in the following three cases : 

G. E., 9et. about 40. A man who had been of an excitable disposi- 
tion, and had led a dissipated life in regard to drink and women, of a 
fiery temper; who had suffered from syphilis, whose whole life had been 
a whirl of mental excitement. He had complained for some time of very 
severe headaches, had been off his sleep, had been unusually irritable and 
not fit to do a day's business. One day he suddenly fell down in a fit, 
and remained in general and severe convulsions with complete stupor for 
about two hours and died in them. After death, I found all the patho- 
logical signs of general paralysis; especially the adherence of the pia 
maUr to the convolutions of the vertex in patches was most marked. 
There was no local disease in the membranes or vessels that has been 
recognized as syphilitic, and he had not been drinking heavily before his 
death. 

My conclusion was that it Avas a case of general paralysis, with a 
strongly convulsive tendency, this killing the patient before the usual 
symptoms had time to develop. I do not know whether I should or not 
have been able to diagnose the case had I seen him before the convulsive 
attack, or whether there were any motor symptoms present before it 
occurred. But, it may be said — Is it possible for a man to have marked 
disease of the brain affecting the convolutions of the vertex, without 
mental or motor symptoms ? My experience of general paralysis would 
lead me to the conclusion that the recognizable pathological lesions of the 
convolutions precede the mental symptoms. They usually need to develop 
in some intensity, and to involve a certain number or hind of convolutions, 
before mental or motor symptoms become very manifest. 

I had a general paralytic in the asylum, G. A., who took an epilepti- 
form convulsion every da}^ for months. The temperature rises often 
before, and always after, an epileptiform convulsion or a mere congestive 
attack in these cases. I had another patient who had many epileptic- 
looking fits for a year, and who was treated for epilepsy by eminent physi- 



GENEKAL PARALYSIS. 269 

cians during that time, before the usual mental and motor signs of general 
paralysis appeared. 

The next marked departure from the normal type of general paralysis, 
such as I have described it, is where the first stage consists of maniacal 
exaltation alone, without any motor sign that one can recognize, for 
months, and even years. I have had several cases now who had what 
appeared to be attacks of ordinary acute mania, and to all appearance 
had recovered, who had even second attacks and recovered, and then 
developed the motor symptoms of general paralysis. The following is 
one of them : 

G. G., ast. 36, an Irishman born (Irishmen often enough suffer from 
general paralysis here if they do not at home), drunken and hard work- 
ing; married. Had an attack of "acute mania" in 1876, and was sent 
to the asylum, and "recovered" in five weeks. No motor signs or 
evidences of general paralysis were noted by me or anyone else here. In 
1878, he had another attack, and this time some suspicion of the disease 
was excited, but no diagnosis made. He was again discharged recovered, 
and it was only on his third admission, three years after his first, that the 
disease was manifest. He died of it in three years. I lately saw a case 
with Dr. Bramwell, in which I had no doubt whatever as to the nature 
of the disease, and have none now,, in which the symptoms w^ere those of 
the second stage, with indistinct articulation, difficult walking, great 
mental facility, epileptiform convulsions, and bed-sores, and yet he has 
so far improved that he has gone to work as a draughtsman, and is said 
to be doing his work well. 

In such a case as that of G. Gr., I have no doubt whatever that the 
first attack in 1876 was really a part of the general paralysis, but at that 
time the disease was probably superficial in the cortex and confined to a 
limited area, and did not involve to any extent the motor centres in the 
convulsions, causing, no doubt, much congestion and much vesicular 
overactivity in the cortex, but not incoordination of motion. The first 
attacks were brain storms that passed away, so far as the active congestion 
and the vascular disturbance were concerned, leaving the incipient organic 
convolutional change there, but quiescent. I have also no doubt — in fact, 
I obtained clear evidences of it from his wife — that intellectually he was 
weakened after the first attack of "acute mania" in 1876. Such cases 
enable one to understand the "recoveries" and "cures" of general paral- 
ysis, not one of which, I believe, was ever real or lasting. 

It is common to have in the beginning of the first stage very acutely 
maniacal mental symptoms, and no motor signs to be discovered, and 
general paralysis should never be diagnosed from mental symptoms alone. 
I had a case, G. H., who was most acutely maniacal, very dangerous, very 
homicidal, very impulsive, and very strong willed and unmanageable for 
twelve months before there were any motor symptoms that enabled mo to 
diagnose general paralysis. From the state of his pupils, and the looks 
and expression of his face, I suspected it, but I could not have said 
definitely it was any other condition than acute mania for the first twelve 
months. It is very uncommon for a man who sufters from general 
paralysis to have been insane before, but I have met with a few examples. 
One, G. H. A., had an attack of mania in youth, recovered, kept aycII. 



270 GENERAL PARALYSIS. 

and did his ordinary business for twenty years, and at the age of forty- 
four became a general paralytic. 

We have certain long-lived cases that do not die at the normal time, 
but live on for periods up to twenty-two years. I have now under my 
care such a patient. 

G. J., aet. 35, admitted to the Royal Edinburgh Asylum 18th Novem- 
ber, 1860. Had led a somewhat rough life, and nine months before had 
an "epileptic fit." No heredity to insanity, but he had a very eccentric, 
somewhat silly sister. The attack had been preceded by a melancholic 
condition, and he had refused his food. His articulation was slurred, his 
pupils unequal, his walk slow and unsteady. He was unhesitatingly 
diagnosed as a general paralytic. After nine months he was taken out 
of the asylum by his relatives, but had to be sent back again in eighteen 
months, having been, while outside, totally unable to do anything for his 
own livelihood, and having got gradually worse in mind and body. When 
admitted in 1863, he was "stout, stupid, and silent," had the "peculiar 
expression of face of general paralysis well marked, as well as its walk." 
Some days he was "quite well and happy." In a few months, he was 
"uproariously happy," with the most exaggerated notions about his 
riches, strength, height, beauty, etc. He is forty feet high, is God, is 
married to the Queen, is the strongest man in the world, and has a 
"damnable heap of money." All Leith Docks belonged to him, and 
most of the ships there. In December, 1863, he had a series of epilepti- 
form fits, which were ushered in by a regular congestive attack. He 
became very weak, and could with difiiculty articulate, or make his water. 
He got over this condition in a few weeks, and became facile and con- 
tented. An assistant physician of the asylum recorded in the Case-book 
in 1864 — "Is a magnificent specimen of a general paralytic." In June, 
1864, he had a congestive attack, succeeded by epileptiform fits, being 
maniacal and restless afterwards. In August, 1864, he had another 
congestive attack, and one in January, 1865, and got so fi^ail in March 
that he had to be kept in bed. In March he had another congestive 
attack. He had no congestive or epileptiform attack again till December, 
1880. During all these years the symptoms remained the same, but the 
disease did not advance much till after the epileptiform attack in 1880. 
The period of general convulsion was short, only a few minutes, but he 
was confused and stupid afterwards for four hours, and was then excited 
and noisy. The paresis increased after this, and the general strength 
failed much. In February, 1881, he had another severe attack of gen- 
eral convulsions, with several hours of stupor following them, the tem- 
perature rising to 102.4° in three hours, and then falling to normal in 
two hours after that. He had two such attacks in April of that year. 
After the last the left side was found weaker than the right, and he was 
shaken generally. During the summer he could not walk far without 
becoming paralyzed in his legs ; he had incontinence of urine, his speech 
was thicker and less articulate, and mentally he was more facile and 
stupid. 

At present (November, 1882) twenty-three years after the commence- 
ment of his illness, his condition is as follows : Facial expression vacant ; 
pupils both contracted, but partly sensitive to light, the left being slightly 



GENEKAL PARALYSIS. 271 

the larger, outlines not regularly circular ; tongue tremulous, and its 
muscles incoordinated over surface; articulation affected just like that of 
a typical general paralytic at the end of the second stage of the disease, 
difficult words being worst pronounced, and the ends of sentences worse 
than their beginning ; walk uncertain, dragging,' straddling ; sensibility 
diminished, can smell pepper, but cannot be made to sneeze ; spinal reflexes 
very acute, patellar tendon reflex quite absent. Often has retention of 
urine. Begins a walk pretty well, but soon fails, and cannot progress at 
all ; turns round with difficulty ; cannot stand on one leg ; whole nutrition 
flabby ; mentally in a facile, morbidly contented, exalted state. 

It may be said that, as he has not died, it is impossible to say that this 
is a case of true general paralysis. If he is not, he has had every 
symptom of the disease except its termination in death, and neither 
Dr. Skae nor I, nor one of the score of assistant physicians here who 
have had charge of him, has had any doubt on the subject. 

The common age for the occurrence of the disease is between twenty- 
five and fifty. The chart in Plate VI. shows its prevalence in one 
hundred and four cases admitted to this asylum as compared with mania 
and melancholia, and the ages at which it occurred. The greatest 
number of cases occurred between forty and forty-five years. But there 
are a few exceptional patients. Wq have had at Morningside two cases 
under twenty, one at sixteen, and the other at twelve, accounts of both of 
which were published, one by Dr. Turnbull, and one by myself. The 
diagnosis in both being confirmed by 2^, post-mortem examination, there 
could be no doubt as to the nature of the disease. 

Instead of the exalted condition of mind, or the merely enfeebled and 
facile one, we have a few cases (from three to four per cent, in my expe- 
rience) with melancholic symptoms. My belief and experience is that in 
all these there is some organic visceral disease which transmits to the con- 
volutions sensations that are disagreeable and depressing. On examina- 
tion of our pathological register, I found that nearly all the cases of the 
disease that had tubercular disease or broncho-pneurdonia had been 
melancholic. I had a man, Gr, K., who had the fixed melancholic 
delusion that a man was inside him who annoyed him constantly, and 
made him really depressed, and after death we found tubercular disease 
of the intestines. I have a most instructive case now showing the 
infiuence of visceral disease on the mental condition of a general 
paralytic, G. L., a cabman, who thought on admission he had .£30,000, 
and got £1000 from Queen Victoria for driving h.er along Princes Street. 
Suddenly one day he became melancholic, saying he was a beggar, and 
crying bitterly. We examined his chest and found he had bronchitis. 
The reflex action was so dulled, as in most cases of the disease, that he 
had no cough, felt no pain, and made no complaint. As his bronchitis 
improved, his mental elevation and delusions of grandeur returned. lie 
had a relapse, and the melancholic state at once came back. For a week 
or so he was elevated one day and depressed the next. At last tlio 
bronchitis was recovered from, and he is the happy imaginary possessor 
of his thousands. Whenever I see a general paralytic dull now, I always 
search for an organic visceral cause, and usually find it. 

I had one case of the disease, Gr. M., that began with aphasia, and was 



272 GEKEEAL PAEALYSIS. 

treated for several months for this. As he began to speak, the peculiar 
articulation was noticed, and he died in about two years. In his case, 
the motor reflex excitability of the brain and cord was greater than 
I ever saw in any case w^hatever. A very slight tap on the toe would set 
up a convulsion first in that leg, and then in the next ; a slight pufi" 
suddenly into his face would make him jump off" his seat with his whole 
body. I have many times seen general paralytics aphasic after conges- 
tive attacks. In such cases, and in all cases where the speech was 
specially afiected during the disease, I have always found after death 
that the third frontal convolution of the left side and that region of the 
brain had the pia mater especially adherent to the cortex. 

I have only seen one patient in which long-continued ordinary insanity 
became changed into general paralysis. It was a case of dementia of 
twelve years' standing. It was an exception that proves the rule that 
general paralysis and ordinary insanity have nothing in common patho- 
logically. 

The conditions that are most apt to be mistaken for general paralysis 
are alcoholism, syphilitic insanity, paralytic insanity, certain cases of 
epileptic insanity, acute mania with ambitious delusions, choreic msanity, 
some senile conditions, some traumatic cases, and some imbeciles with 
stuttering speech. 

Pathological Appearances in the Brain in General Paralysis. 
— At this point I think it is better to complete the clinical history of the 
disease by describing very shortly the pathological appearances met with 
in the brain. The encasings and supports of the organ are all found to 
be afiected, and the longer the case has lasted the more marked are the 
changes met with. The bone of the calvarium is denser and harder, in 
many cases the diploe being obliterated, and in many others there is a 
distinct layering and deposit of new bone on the inside of the inner 
table of the skull-cap, this being usually confined to the frontal and 
parietal bones. The dura mater is thickened, adheres more or less mor- 
bidly, and frequently leaves shreds attached to the bone. In many cases 
I have seen spicula of bone growing in it at the junction of the falx, 
which is always much thickened. When the dura mater, often in layers, 
is refiected, the most characteristic morbid appearances of the disease are 
seen. I have endeavored to depict some of them in Plate I. (see Frontis- 
piece). 

In a number of cases we find, under the dura mater, and attached to 
it, lying between it and the arachnoid, a new substance of a morbid and 
peculiar kind, commonly called a false membrane. It varies in consist- 
ence from the fibrous texture of the dura mater itself to a fibreless jelly, 
in color from a grayish-Avhite to that of a blood-clot, in thickness from a 
film to a quarter of an inch, in extent from a small patch or two to 
a covering of both hemispheres above and below. It is usually thickest 
over the vertex. In some cases it looks like a clot, in othera like an 
extra layer of dura mater, but it can always be easily scraped away. 
When it is removed from the dura mater that membrane is not congested 
or infiamed looking. It always contains new bloodvessels, and nearly 
always blood-corpuscles or blood-coloring matter. On microscopic 
examination it is found to consist of a newly organized fibrous tissue, in 



GENERAL PARALYSIS. 273 

a gelatinous matrix with much granular matter, white and red blood- 
corpuscles, and newly formed and forming capillaries with tender walls. 
This is the so-called pachymeningitis hcemorrhagica interna of the 
Germans, a ridiculous and misleading name, for it is not the result 
of inflammation at all. The formation of the substance is, to my mind, 
foil of interest and instructiveness. It implies a very great intensity of 
morbid action in the convolutions, and probably also great and sudden 
changes in the blood pressure within the cranium. 

Under the membrane if present, and under the dura mater if not 
present, we see in all well-marked advanced cases the appearance 
presented in Plate I. on the anterior lobe. The arachnoid is immensely 
thickened, and either mottled with white spots or striated along the sulci 
with white fibrous-looking bands. Under it there is what looks like 
a dull opaque jelly, through which the convolutions dimly appear, and 
under which great tortuous congested veins meander ; some of these 
being perhaps, if the case has died during or after a congestive attack, 
obstructed by little white masses of hard ante-mortem clot. But this is 
not really a jelly, for if the arachnoid is pricked it nearly all oozes out as 
a dirty opaque fluid, which varies from two to six ounces in quantity. 
This is a really compensatory fluid, filling up the space left vacant by the 
atrophy of the convolutions and brain generally. It does not nearly 
represent the whole of the brain atrophy, for we have, in addition^ 
enlarged ventricles and dilated perivascular spaces, which often contain 
six ounces more of fluid. After the fluid has drained off", the pia mater 
and the convolutions are better seen. Both are strikingly abnormal. 
The pia mater is thickened, vascular, and tough to an enormous extent. 
The convolutions are atrophied, especially over the vertex of the anterior 
and middle lobes and in some localized places elsewhere, and generally 
tend to be wedge-shaped, and to lie loosely together. When the pia 
mater is removed from the convolutions (do this in every case of mental 
disease you examine), it is found to adhere to and raise up portions of the 
outer layer of the gray substance on the ridges of the convolutions 
(seldom in the sulci) which stick to the pia mater, are removed with it, 
and appear as irregular patches over the membrane that has been 
detached from the brain (see lower part of Plate I.). The convolutions 
from which those patches have been removed look eroded like the surface 
of a cheese where a mouse has been (see middle portion of Plate). Now, 
this adhesion of the pia mater to the convolutions is a very morbid 
phenomenon. It has never been found to any extent in any patient 
whose mind was sound and strong before death. It is, in diiFerent cases, 
confined to a few convolutions, or is general over all the brain. It is by 
far most frequently confined to the vertex and to the anterior and middle 
lobes, and to the gyri round the olfactory bulbs at the base. The two 
hemispheres usually adhere anteriorly, and in the attempt to separate 
them some of the substance of the convolutions will be torn away. In 
some cases we find this adhesion of tlie pia mater at the base, over the 
orbital convolutions and the middle lobes. I have never seen the tips of 
the posterior lobes much a,ffected. They are usually healthy Icx^king. 
Though the adhesion is only partial in most cases, I iiave seen it almost 
universal. It merely represents, in my opinion, the acme of a pathological 

18 



274 GENERAL PARALYSIS. 

process that is very general in the convolutions. In examining the 
diiferent convolutions of the brain of a general paralytic microscopically, 
and the different parts of one convolution, we find that, though the 
morbid appearances are in greater intensity in one place than another, 
they by no means coincide in absolute intensity with the parts to which 
the pia mater has adhered. I have found as much disease microscopically 
in a convolution to which it did not adhere as in those to which it did. 
There is rarely or ever much adherence of the pia mater that dips down 
into the sulci, and I have never seen one convolution adhering to the 
next. This fact alone has always settled the question, in my judgment, 
that the disease is not of inflammatory origin, using that word in its 
ordinary sense. The fact is, that the pia mater which dips in and 
separates adjoining convolutions is different in composition and use from 
that portion which overlays the whole brain. The former contains no 
lymphatics, and is a mere fine network of fibres to hold the vessels, while 
the latter is full of lymphatic spaces. 

On section the gray matter of the convolutions affected is usually 
divided into two distinct layers, the outer being gray and opaque looking, 
and there is often a line of red congestion as the demarcation between 
those two. Along this line the brain tissue seems softer and more 
pultaceous. There is no real sclerosis, though, on the whole, the outer 
layer of the gray substance may be slightly harder in texture than 
normal. In some cases, however, it is distinctly softer. The whole gray 
matter is thinner, especially in the cases that have lasted long. The 
white substance is often very congested, especially in irregular patches (as 
seen in Plate III.), its perivascular spaces are always enlarged, and the 
small tessels tough and their coats thickened. 

On opening into the ventricles they are nearly always found enlarged, 
but the most striking peculiarity is, that their normally delicate epithelial 
linings are toughened and roughened in an extraordinary degree. Their 
surfaces look in the less marked cases like frosted glass, in the more 
marked cases they are granular, and even minutely nodular, feeling rough 
to the touch. They are leathery, too, when torn. This condition is 
usually most marked in the floor of the fourth ventricle, and the cover- 
ing of the calamus scriptorius is always a grayish, gelatinous-looking, 
but really tough membrane. The microscopic examination of a section 
of such a granulation at once shows what has taken place (see Plate YIL. 
Fig. 3). The single normal layer of delicate epithelium has become 
enormously hypertrophied, and has thrown itself up into great nodular 
masses of epithelial cells, arranged in some cases in layers of one 
hundred cells deep. In the deeper layers the cells have become flattened 
and hardened, so that they have a fibrous appearance, and the brain 
substance on which they rest has undergone a process of sclerosis. Those 
granulations are in fact innumerable epitheliomata growing over a 
fibrous membrane. There is no single tissue in the brain w^hose condi- 
tion is so morbid as the epithelial linings of the ventricles. This is 
another proof, if any were needed, that general paralysis is not an 
inflammmation proper, for in inflammation the first thing the epithelial 
cells do is to fall off while it lasts. 

A microscopic examination of sections of the convolutions (see Plate 



GENERAL PARALYSIS. 275 

yil., Fig. 5) shows enormous proliferation of the neuclei of the neuroglia, 
which takes place most along the small vessels and capillaries. The 
outermost layer of the convolutions is thinned, altered in appearance and 
structure, and in the advanced cases converted into a dense unorganized- 
looking texture, instead of the beautiful and regular layer of small cells 
and fine granules of a healthy convolution. The larger cells further in, 
and the large multipolar cells, are more or less degenerated or atrophied, 
especially in patches and areas. The bloodvessels are diseased, their 
coats being thickened and full of nuclei. Sometimes they are obliterated 
and thready. The perivascular canals are morbidly enlarged, sacculated, 
and filled with all kinds of organic debris, blood coloring-matter, 
granules, and minute apoplexies. There can be no doubt that those 
canals and the spaces in the pia mater act as lymphatic ducts. Having 
been obstructed during life, little effete material could have been carried 
along them. 

There is no nervous tissue that is not found diseased and degenerated in 
advanced cases of the disease, the retina, the peripheral nerves, the 
sympathetic ganglia, etc. 

Nature of the Disease. — What, then, is general paralysis ? There 
are few diseases whose essential nature we as yet know. But we know 
that the special trophic energy and inherent physiological qualities of 
different tissues become perverted in special ways, so that most tissues 
have their own special types of disease. There can be no doubt that the 
gray substance of the convolutions of the brain of man is the highest in 
quality and function of any organic product yet known in nature. That 
substance reaches its highest development in the male sex between 
adolescence and middle life. Its uses are called forth in the highest 
degree in the European races who live in towns. Its physiological abuses 
by alcoholic and other poisoning, by over-strain, by violent energizing 
stimulated by continuous strong mental and other stimuli up to the point 
of exhaustion, are also most common under those circumstances. Its 
outer layer or rhind is most delicately constituted, has far more blood 
(see Plate VII., Fig. 5) and more minute cells than any other portion of 
the brain, and, on the whole, may be regarded as the most important 
factor in mentalization, being in fact the mind tissue. Immediately 
underlying it in the convolutions, in certain parts of the brain, Ave 
probably have the originating motor cells. This outer rhind of gray 
matter, this last evolved and highest organic substance, is precisely that 
affected in general paralysis. The proof goes to show that this is first 
affected in the typical cases, and that all the other nervous degenerations 
which finally affect the whole nervous system are subsequent and sequen- 
tial. Granted a progressive and incurable disease of this mind tissue, 
towards which the whole of the rest of the nervous system tends and in 
which it ends, which controls and regulates it all, and which is its crown 
and highest development, it is quite explicable that all the rest of the 
nervous system should degenerate in structure and function, and in fact 
die slowly and progressively. It is a quality of nerve tissue to degen- 
erate in the lines of physiological activity, when that activity ceases 
either in a higher centre or in the part innervated. General paralysis is 
a disease of this outer layer of the cerebral convolutions — of tlie mind 



276 PARALYTIC INSANITY. 

tissue in fact. It is essentially a death of that tissue. I look on it as 
being equivalent to a premature and sudden senile condition, senility 
being the slow physiological process of ending, general paralysis the 
quick pathological one. The causes of it are causes that have exhausted 
trophic energy by over-stimulation. Its first stage is accompanied by 
undoubted morbid vaso-motor dilatation, so that all the tissues enveloping 
the brain, and holding its elements together, receive an abnormal supply 
of blood, and thereby acquire tissue hypertrophy — the bones of the skull- 
cap, the membranes, the reuroglia, the epithelium, and the arteries. 
Just as the tissue degenerations, especially the brain degenerations of old 
age, cannot be arrested, and are necessarily progressive, so is general 
paralysis. Those high nerve cells have lost their once inherent power of 
self-restoration, and so they degenerate and atrophy. The diseased 
process is peculiar, because the tissue in which it originates is peculiar. 
Its motor accompaniments are really not more inexplicable than the 
ordinary senile speech and senile incoordination. 

Local Distribution. — General paralysis prevails in some places and 
in some races, and is unknown in others. As yet the Asiatic is not 
subject to it, the savage is free from it, and the Irishman and Scotch 
Highlander needs to come to the big towns or to go to America to have 
the distinction of being able to acquire it. The female sex is very un- 
susceptible of it, but if women drink bad liquor and live riotous, excited 
lives, as in the cotton and manufacturing districts of England, they too 
will become general paralytics. I have only seen one female in the rank 
of a lady suffering from general paralysis. The things that most excite 
and at the same time most exhaust the highest brain energy are those 
that tend most strongly to cause the disease, viz., over and promiscuous 
sexual indulgence combined with hard muscular labor, a stimulating diet 
of highly fed flesh meat, the brain being all the while excited and poisoned 
by alcohol and syphilis, all these things being begun early in life and kept 
up steadily. In this country the Durham miner, when earning good 
wages, fulfils the most perfect conditions yet known for the production of 
general paralysis. Every sixth lunatic admitted to the Durham County 
Asylum is a geneal paralytic. Hard study, or severe mental shocks, or 
traumatic injuries, or continuous anxiety, will also produce the disease. 
I do not think there is any proof that it is syphilitic m origin. 



PARALYTIC INSANITY. 

Paralytic Insanity, or Organic Dementia, is that form of mental dis- 
turbance which accompanies and results from such gross brain lesions as 
apoplexies, ramollissements, tumors, atrophies, and chronic degenerations 
of the brain, affecting the convolutions and their functions either primarily 
or secondarily. It has nothing whatever to dj with general paralysis. 
Its symptoms vary according to the position, kind, and intensity of the 
pathological process. But it is typically a dementia, an enfeeblement, a 
lessening of the mental power, superadded to some sort of motor paralysis. 
Along with this enfeeblement there may be, and there usually is, a certain 
amount of depression at first, followed afterwards by a mild exaltation and 



PAKALYTIC INSANITY. 277 

emotionalism of a childish kind, this gradually passing off and leaving the 
patient, if he lives long enough, forgetful, helpless, and torpid. Paralytic 
insanity, like general paralysis, has a gross and demonstrable pathological 
basis, but it differs v^idely and essentially from it in not being a specific 
disease of the brain convolutions, in not running a progressive course, in 
not being necessarily incurable, in the irregularity and variety of the 
mental symptoms present, and of the pathological lesions. It is best and 
most commonly seen in a case where there has been apoplexy from rupture 
of a bloodvessel in one of the great basal ganglia, or embolism, or throm- 
bosis, followed by local starvations of brain tissue, and ramollissement ; 
those destructive processes cutting off large tracts of the convolutions by 
destroying part of the projection and association systems of fibres by 
which the convolutions are brought into connection with the basal ganglia, 
the cerebellum, and the cord and the muscles, or with each other. This 
interruption may of itself sensibly affect the mental power, and those 
pathological processes tend to advance up into the convolutions, so de- 
stroying the sources of mental energy directly. A brain affected by 
apoplexy or embolism, and in that case probably having its bloodvessels 
generally diseased, is an organ on the verge of dissolution. Such pro- 
cesses are the beginning of the end in most cases, and the mental symp- 
toms are often the most prominent and by far the most troublesome. 
Yet, after all, they are not the essential part of the disease. This disease 
is not an insanity in the popular acceptation. In most cases the gradual 
mental decay is never thought of as a mental disease at all. It is rather 
looked on as a necessary and natural accompaniment of the bodily disease. 
In most cases it is not at all beyond the ordinary nursing capacity and 
management available in the patient's home, if he has any money or 
relatives at all. The very poor in the great towns, when affected by it, 
are sent to workhouses, and not usually to asylums for the insane. It is 
only the worst and most troublesome cases that it is necessary to send 
there — the noisy, the restless at night, the very dirty, the troublesome. 
Motor restlessness is a special characteristic of the worst class of cases, 
and this often needs, for the protection of the patient, special nursing 
and special rooms. But there is no essential difference between the 
helpless hemiplegic whose memory is gone, his energy impaired, his 
thinking capacity paralyzed, and his affective power deadened, who sits 
in his easy-chair at home, and the restless, shouting, sleepless paralytic 
insane man in the hospital ward of an asylum. 

The heredity of the patient plays an important part in the origination 
of paralytic insanity of the more marked kind. While a man with no 
nervous heredity will have a large spot of progressive softening in one of 
his corpora striata, and yet will be calm, reasonable, and quite manage- 
able, tliough forgetful, torpid, and emotional, the man with a bad nervous 
heredity will become, under the same conditions, restless, depressed, noisy, 
and sleepless. There is no doubt that apoplexies and all sorts of other 
gross limited lesions produce, in unstable brains, great convolutional dis- 
turbance through reflex excitation. If such brains are unstable in their 
motor centres, we liave convulsions, local or general ; if there is heredi- 
tary mental instability, then we have the ordinary symptoms of mania or 
melancholia. I had once as a patient a young woman ((^. X.) under 



278 PARALYTIC INSANITY. 

thirty, who, having heart disease, became hemiplegic on her right side, 
and aphasic after the birth of a child. Immediately after these came on 
great mental depression, with suicidal tendencies, for which she had to 
be sent to an asylum. The hemiplegia soon passed quite away, but the 
aphasia remained all her life ; and when the mental depression passed off 
in a few months she gradually became exalted, and remained so for some 
months. Then she again became depressed, and was mentally a typical 
case of alternating insanity {folie circulaire) for the seven years she lived 
after this. She at last died of the heart disease, and I found Broca's con- 
volution almost destroyed by an old embolism, but the rest of the brain 
with only the traces of repeated excitations and congestions. In this 
case, which I mention as being a very rare and most unusual kind of 
paralytic insanity, the embolism and its consequences no doubt excited 
into pathological activity a previously existing hereditary weakness of 
the mental portions of the convolutions which had before that been stable 
in their working. In the more typical cases of paralytic insanity the 
same thing occurs in old and partially worn-out brains. 

There is a close analogy in symptoms, pathology, and course, between 
paralytic and senile insanity. In fact, the majority of paralytic cases are 
also senile. In a brain with general senile degeneration and diseased 
arteries, a local lesion occurs, and we have it exciting and lighting up a 
general convolutional flame. I have had many cases where there was a 
family tendency to mental disease, but it had never shown itself in any 
actual symptoms till the very end of life, when an attack of paralysis 
occurred, and this was followed by melancholic or maniacal symptoms 
and subsequent dementia. I have had several such patients whose 
children had become insane at an early age long before them, but they 
remained well till they became hemiplegic. One such case was G. 0., 
aet. 67, who remained quite well mentally, and did his work till he had 
a slight attack of left hemiplegia. Then he became melancholic, sleepless, 
and suicidal, and had to be sent to the asylum, where his daughter, G. P., 
had been a patient for thirteen years, suffering from essential paralysis of 
infancy on the right side, epilepsy, and dementia. 

The motor symptoms in paralytic insanity must be regarded as integral 
parts of the disease. The speech is the most characteristic of these in 
the ordinary hemiplegic cases. It is a thick articulation, not a tremulous 
speech. Every word from the beginning of a sentence to the end is im- 
perfectly pronounced. There is no tendency to fail more at the end of a 
sentence than at the beginning. The labial and facial muscles do not 
quiver before or during the articulatory process, as in general paralysis, 
though the tongue usually trembles when put out. It is a simple paretic, 
not a convulsive, speech. Long, difiicult words and sentences are 
attempted, and got through with in a way, but are not found impossible 
of attempt, or end in a more inarticulate prolonged vowel sound, as often 
in general paralysis. In the latter disease it is essentially a convolu- 
tional lesion speech ; in the former it is a basal motor ganglia lesion 
speech. In the former it is the originating motor speech coordinations 
in the convolutions that are affected, in the latter the secondary coordi- 
nations lower down. In very many of the paralytic cases we have 
apoplexies and similar lesions of the convolutions themselves, and in such 



PARALYTIC INSANITY. 279 

the speech symptoms are always more like those of general paralysis. 
In such patients, too, we are apt to have epileptiform, epileptic, and con- 
gestive attacks. In many instances, even when the original lesion has 
been in the corpora striata or in the motor fibres of conduction near it^ 
destruction of tissue will go on up to the convolutions ; in fact, if the 
patient lives long enough it is sure to do so, and the speech will become 
more like that of the second stage of general paralysis. 

I need hardly say that if the lesion affects the posterior portion of the 
third frontal convolution of the left side, or the Island of Reil on that 
side, or the fibres of communication inwards from those parts, or certain 
portions of the extra-ventricular nucleus of the corpus striatum of that 
side — in such cases we will have the aphasic speech symptoms. It is a 
disputed question whether complete aphasia can coexist with perfect 
integrity of the intellectual faculties. If the lesion be strictly limited to 
the speech centre, which it very rarely is, the loss of mental power may 
be slight, but whether we can have mental completeness according to the 
previous standard of perfect health of the individual is another matter. 
I do not believe we can have such completeness if we could apply proper 
tests. I have never seen a case where it existed. 

Here is a kind of case, very common indeed where extreme bodily 
helplessness coexisted with such mental symptoms as made the patient's 
presence almost intolerable in a private house, and even to the neighbors 
who lived near. 

G. Q., 8et. 64. Had an attack of apoplexy with left hemiplegia four 
months before it was necessary to send her to the asylum. Her mother 
died of apoplexy at the age of eighty-four. There was no other neurotic 
heredity discoverable. During the first month after the apoplexy she 
was stupid and half comatose. Then she began to have hallucinations 
of sight, and to be fanciful, irritable, and very unreasonable, to sleep 
badly, and to have a morbid craving for food with no sense of satiety. 
The mental symptoms got gradually worse, while the hemiplegia remained 
complete. She became subject to periodic fits of depression, lasting 
whole days and nights, during which she would cry and scream loudly 
without intermission in a peculiar baby -like voice that penetrated through 
the house and into the street, and was most annoying to the neighbors, 
especially at night. There was no reasoning with or soothing her. It 
was evident that she had a sense of extreme organic discomfort, and that 
she probably had pain. Her delusions all took their origin from her 
sensations. She afiirmed that her left leg and arm did not belong to her, 
and would order that they should be taken away. She affirmed her food 
was poisoned, and she said the people near her were going to kill her. 
She could not attend to the calls of nature, and when moved to be 
dressed and washed screamed at the pitch of her voice. She had no 
memory at all for recent events, but lived in the past. She was very 
emotional, crying nearly every time she was spoken to, but her appear- 
ances of emotion, like the rest of her mental life, were merely automatic. 
She showed no real aifection for her fiimily. She constantly threatened 
suicide. She mistook the identity of those about her, calling strangers 
by the names of old friends. With the hand she could move slie would 
try to tear and destroy and break tilings. After about tliroe months of 



1 



280 PARALYTIC INSANITY. 

this state she had to be sent to the asylum, chiefly on account of the 
noise she made. 

She was fed and nursed and cared for, placed on a water-bed, and 
kept warm, and placed in a room where her noise did not disturb others. 
Sedatives and soporifics, such as the bromides and chloral, were tried in 
moderate doses. They usually did not act in producing quiet or sleep 
till twelve hours after they were given. This is a common thing in 
maniacal conditions. An old night attendant I once had pointed it out 
first to me. He divided his noisy people into tw^o classes — those in whom 
the night draughts produced sleep the night they were given, and those 
in whom they produced sleep only on the following night. Though sleep 
was thus produced in G. Q.'s case, it was not restful or in any way bene- 
ficial, while her appetite was lessened and her strength impaired. After 
frequent repetitions of the bromide of potassium and chloral she got 
quite drowsy, stupid, and would take no food at all. It seemed as if the 
only things to be done with benefit were nursing and feeding. The 
advanced and advancing brain disease being destructive and irritative in 
its character, evidently involving the convolutions to a serious extent, 
seemed capable of no alleviation. She steadily got weaker, and died in 
about four months from the beginning of the attack. No post-mortem 
examination was permitted. The case, looked at from the point of view 
of mental symptoms, was one of melancholia of the excited variety ; but 
the whole of the mental symptoms were so secondary, in a clinical point 
of view, to the attack of apoplexy and hemiplegia, that it is evident the 
appropriate name for such a case is that of paralytic insanity. The 
irregular periodicity in the symptoms, and the days of quiet she had, 
seemed to me — and this is markedly the case in many senile cases too — 
to be merely the stupor and inaction of a spent organ, that could no 
longer evolve morbid energy through sheer exhaustion till an accumu- 
lation again took place. 

The following is a good example of insanity from an advancing 
paralysis, not hemiplegic at first, caused by progressive brain destruction : 

G. R., ast. 57. Habits intemperate. No admitted heredity to the 
neuroses. Four years before admission to the asylum he had some sort 
of attack that was described as "bilious," becoming almost blind after it. 
He then became subject to severe headaches. About fifteen months 
before admission he had a paralytic shock, affecting both sides equally, 
and since then his mental power has gradually become impaired. At 
times he was noisy and unruly in a stupid, purposeless fashion, thinking 
that some one was coming to hurt him. When he could not find his 
razor one day he set fire to his beard. He would attempt to leave the 
house with nothing but his night-shirt on. He slept badly, and was 
restless, and often noisy at night. He used to repeat his former acts in 
an automatic absurd way, e.g., one day was found fishing in his grate 
with a bit of string tied to a stick. His memory especially failed. 

When, on account of the excitement, noise, and difficulty of manage- 
ment at home, he was sent to the asylum, he was not apparently exalted 
or depressed or excited, but he was much enfeebled in mind, his speech 
and behavior being childish, and his memory almost gone. He could 
not tell the day of the week, or his age, or the number of his children. 



PARALYTIC INSANITY. 281 

He expressed no delusions. His power of attention was lessened. He 
evinced no great surprise or curiosity at coming to the asylum. His face 
was expressionless and flabby, his gait dragging and weak, and his grasp 
feeble. His articulation was characteristic of such cases, being thick 
and slurred, but not tremulous. It was simply a muscular inability to 
perform the fine coordinations of speech. The tongue, was furred, flabby, 
and tremulous on its surface. The bowels were constipated. Heart 
enlarged, and sounds impure. The sensibility and reflex action were 
normal. The urine was slightly albuminous. Temperature 98°, pulse 84. 

After coming to the asylum, there was a steady downward course in 
mind and body. He was restless, and very liable to fall over any little 
obstacle and hurt himself. He slept badly. He was perfectly contented 
in mind; but if you spoke in a sympathetic tone, he would burst out 
crying without being able to assign any cause. At first he was able to 
keep himself clean, but soon his urine and then his feces passed without 
his paying any attention. At night he was often noisy and very restless, 
and he needed to have his bed-clothes put on and be attended to by the 
night attendant constantly. Was placed in our infirmary ward, and 
needed much attention by day and night. In four months he was con- 
fined to bed, and almost entirely paralyzed, but still noisy. Then he got 
in a condition of semi-stupor, and in eight months after admission had 
an attack of apoplexy with left hemiplegia and coma, and died in twenty- 
four hours thereafter. The whole disease lasted four years, during the 
last two of which he was partially paralyzed and affected in mind, and 
for the last eight months he needed asylum treatment. A post-mortem 
examination was not allowed. 

The following is an example of the kind of recovery that sometimes 
take place in paralytic insanity : 

G. S., set. 62, a steady, temperate man. His sister was a patient in 
the asylum once. Two years before admission he had had two shocks of 
paralysis on the left side. Since then he has got more and more 
"nervous," and at times noisy and violent. For six weeks before ad- 
mission he had been distinctly insane. He was poor, and poorly attended 
to at home. On admission he was childish, facile, suspicious, and talka- 
tive. He thinks the house is coming down on him, that a surgical opera- 
tion was performed on him yesterday, and that people are watching him 
to do him harm, and many other changing fancies. He could walk, but 
dragged slightly the left leg. He had a paralytic, thick articulation. His 
heart was diseased. He steadily improved undor a good diet, regulated 
exercise and work, and general supervision, till in three months he left 
the asylum quite sane and able to earn his own livelihood, though not 
strong-minded. He worked as a gardener for two years, and then was 
sent back to the asylum with much the same symptoms as at first. The 
mental symptoms and the hemiplegia again disappeared almost entirely, 
and in seven months he was able to leave the asylum. Though not able 
to work much, he has stayed quietly at home with his son ever since — 
for three years now. 

Among the causes of paralysis and paralytic insanity, other tlian 
apoplexies and ramollissements, the most interesting in relation to the 
mental symptoms they produce are brain tumors. Thev are various in 



282 PARALYTIC INSANITY. 

kind, position, and mode of growth, and those conditions all affect the 
symptoms bodily and mental. Some tumors grow slowly, and their 
effects can be traced to intracranial pressure alone. In many such na 
symptoms have been present during life at all, or no symptoms that 
could lead to a correct diagnosis. Other tumors cause violent irritation, 
direct and reflex, in the brain tissues near and distant. Others cause 
destructive lesions, and CwSpecially ramollissements in .the brain tissue 
near them. Others set up slow progressive changes both in near and 
distant parts of the brain and the organs of special sense. Intense 
cephalalgia is undoubtedly the most common sensory symptom. There 
are no headaches like those caused by tumors of the brain. They some- 
times stupefy and "drive the patient mad." Next to those, optic neuritis 
and blindness are the most common symptoms. The motor signs are 
paresis and paralysis local and general, convulsions local and general, 
and congestive attacks ; in these as in other respects, mentally and bodily, 
imitating general paralysis. The mental symptoms most common in 
cases with brain tumor are, first, irritability and loss of self-control, and 
'•change of disposition," then depression, with or without excitement, 
then confusion, loss of memory, muttering to self, loss of interest in all 
things, perhaps delirious attacks, then drowsy half-consciousness, ending 
in coma and death. Such cases may die in a month, or may run on to 
twenty years from the beginning of the symptoms. Different authors 
have had extraordinarily different experiences as to the frequency of 
brain tumors from two per thousand up to twenty-eight per thousand 
deaths among the insane, which latter has been my own experience. It 
is doubtftil whether brain tumors are more frequently found in autopsies 
in lunatic asylums than in general hospitals. 

The following is an interesting and very typical case^ of insanity from 
tumor, which illustrates nearly all the common mental and bodily symp- 
toms of that disease: 

Gr. T., aet. 38. First attack of insanity; no hereditary predisposition 
so far as can be ascertained; was intemperate in his habits, which is 
given as the predisposing cause of his insanity, the exciting cause being 
evidently organic disease of brain ; has shown symptoms of insanity for 
four years. His first mental symptoms seem to have consisted in a 
change of temper, great irritability, and an altered affection for his wife 
and family. His first bodily symptoms were intense cephalalgia and a 
gradually increasing blindness, this last preceding by some time the 
mental alienation. He has been getting much worse mentally of late — 
being excessively irritable, violent to his wife and daughters, very abusive 
and foul in his language, and then would accuse his wife of all the 
violence. He still drank hard when he could get whiskey, and all his 
mental symptoms were very much worse after drinking. He professed 
to be sorry for his violence and bad temper afterwards. The blindness 
became complete, and he also became slightly deaf shortly before his 
admission. During the twelve months before admission he had several 
"epileptic" attacks. He wished to go to the asylum, and walked there 
with a friend. 

1 For this, along with other cases of mine, and more fall observations on the mental 
accompaniments of hrain tumors, see Journal of Mental Science, July, 1872. 



PARALYTIC INSANITY. 283 

On admission he showed slight signs of excitement and confusion of 
mind, but his memory was good. He was quite coherent, and, on the 
whole, sharp and intelligent. Could answer questions correctly, and had 
no delusions. He was a heavy-looking man, with the blind expression 
of face — his features combining the expression of an advanced general 
paralytic and that of a man who is drunk. His gait was affected like that 
of a tipsy man. His speech was thick and rather indistinct. He was quite 
blind, and was deaf in his right ear. He said he had at times cramp in 
his legs. Reflex action in legs normal. Right pupil more dilated than 
left, and both nearly insensible to light. Lungs and heart normal. 
Appetite good, tongue very white, bowels costive, temperature 97.8°, 
pulse 72, good. 

He remained in the state described for the first fortnight, except that 
on the very slightest provocation he became wild with passion — com- 
pletely losing control over himself, and capable of doing any violence to 
those about him. In a fortnight he had a severe epileptiform fit, and was 
quite unconscious after it, but he was as usual next morning. He had 
such attacks frequently ever afterwards. For the first six months there 
was little change in him. After that he got more obtuse in mind, weaker 
and more paralyzed in his legs, his articulation thicker and more indis- 
tinct, his pharynx more insensible atnd paralyzed, so that he would have 
choked himself on any solid food. In nine months his legs were quite 
paralyzed, and his conjunctivae became at first injected and then ulcerated, 
with ulcers of the corneae. During the whole time he suffered from the 
disease, an excessive irritability with violent paroxysms of passion, often 
coming on without any cause, were his chief mental characteristics. 
Towards the end of his life, a clouding of his faculties took place, he 
slept much, and immediately before death he was semi-comatose. Reflex 
action in his legs continued very acute to the last. He died in ten 
months after admission, and about five years from the beginning of the 
disease. 

At the post-mortem examination the following appearances were found : 

Head. — Calvarium hard and heavy, but not very thick. When it 
was removed a very curious appearance was presented. Over the surface 
of the dura mater there were a great many little cauliflower-like ex- 
crescences scattered irregularly, being most numerous along the middle 
line, and the largest in the locality of the Pacchionian bodies. The base 
of each was surrounded by a bulging of the dura mater, and where 
attached to this each was quite small, forming a short pedicle. They 
varied in size from a pea to a bean ; they looked like little projections 
of brain that had been made to squirt out through small holes in the 
dura mater by slow steady pressure from within — little hernia^ of the 
brain. Each had a very thin fibrous covering continuous with the dura 
mater. In color they resembled a mixture of gray and white substance : 
in consistence they seemed to be nearly that of ordinary brain convolu- 
tion. Each had a clearly cut bed absorbed out of the bony skull-cap, 
only leaving a transparent plate of bone. There Avas a large one over 
the right orbital plate, the size of a bean, causing complete absorption of 
the bone, so tliat it projected into the fat behind the eye. On attempting 
to raise the dura mater, it was found that this could not be done without 



284 PAEALYTIC INSANITY. 

tearing the connection of these herniiTe with the convolutions. At the 
narrowest part of the neck of each, as it passed through the dura mater, 
it consisted of both white and gray matter, so that when torn oiF there 
was a small white spot like a pin's head in the convolution from which it 
sprung. On section it was seen that this white substance passed through 
the gray matter of the convolution like a stalk, and was continuous with 
the ordinary white brain substance ; and outside of the dura mater it ex- 
tended into each hernia, swelling out and forming its centre, with a thin 
covering of gray substance. By gentle pressure from without a consider- 
able part of some of the excrescences could be pressed back ; the hernia 
could, as it were, be partially reduced, but this broke up to a greater 
extent what was evidently slightly softened brain substance already. 

When the brain was lifted up a large tumor was found attached to the 
right side of the cerebellum and along part of the right crus cerebri, 
pressing on, and causing partial absorption of that part of the pons 
Yarolii and cerebellum. It was firmly attached to the fibrous portion 
of the temporal bone, causing absorption of the bone, and entering into 
and disorganizing the internal ear of that side. It pressed on the lower 
portion of the middle lobe of the cerebrum, causing complete ramollisse- 
ment there, so that the fluid in the ventricle ran out at that part. The 
tumor was hard and fibrous in some parts, soft and cystic in others, gray 
in color, and somewhat irregular in outline, being altogether about as 
large as a hen's egg. 

The ventricles were much enlarged, and contained much fluid. On 
section there were spots of ramollissement over right orbit, at base of 
middle lobe of right side, and in corpus striatum of right side, the white 
substance being generally doughy. Optic nerves and tracts gray and 
fibrous. 

Microscopic Examination. — On a microscopic examination of the 
brain substance in the fresh state, the covering of each excrescence was 
found to consist of fibrous tissue, being thinned dura mater. The inside 
consisted of masses of granules, and in some places there was a striated 
appearance, being the remains of white nerve-fibres. The arteries were 
coated in most places with granular matter. On examination of the 
pedicles of the excrescences, the granular cells were not so numerous, and 
the striation of the white fibres was perfect. At the surface of the brain 
the appearance was that of healthy white brain substance. Altogether 
the morbid appearances were more marked at the outside of each hernia. 
On examining sections of convolutions, hardened in chromic acid, and 
cut and prepared by Stirling's method, it w^as found that the bloodvessels 
were very much enlarged and tortuous, and surrounded by granular 
matter and a great number of round vacant spaces in each section. 
Probably these had contained some morbid product, such as masses of 
granular matter, which had fallen out, or been dissolved by the turpentine 
and spirit in the process of preparation. 

Statistics of Paralytic Insanity. — In the nine years, 1874—1882, 
we have had, out of 3145 admissions to the Royal Asylum, Edinburgh, 
91 cases diagnosed as paralytic insanity. That is nearly 3 per cent. Of 
those 91 cases, 17, or almost 19 per cent., recovered mentally. This was 
one of the results of statistical inquiry into special forms of insanity that 



PAKALYTIC INSANITY. 285 

surprised me. Had I been asked before, I slaould have said that it was 
quite a rare thing for a case of paralytic insanity to recover. But this 
shows that when a gross lesion of the brain first occurs, it often sets up 
a convolutional storm of mania or melancholia, which is temporary and 
curable. The immediate mental eifect is of the nature of a reflex irrita- 
tion, or temporary vascular congestion, which subsides like any other 
maniacal or melancholic attack. Ten cases were discharged more or less 
improved, in addition to the seventeen recoveries. Forty-six of the 
patients have died up to this time, in thirty-six of whom post-mortem 
examinations were performed. 

Pathology of Pakalytic Insanity. — Looking at the pathology of 
paralytic insanity, as disclosed in the records of the pathological appear- 
ances found in those thirty-six cases, one sees that ordinary brain dis- 
integrations ("white and yellow softenings") from embolism and throm- 
bosis stand as the' most frequent lesion. These "softenings" existed in 
eighty-three per cent, of the cases. Their most frequent original seat 
was in the basal ganglia, but in most of the cases the disintegration had 
extended into the white substance round those ganglia more or less. In 
only about twenty per cent, of the whole number was there manifest dis- 
integration of the convolutions. In four of the patients the lesion was 
confined to the convolutions, was, in .fact, a true disease of the convolu- 
tions alone. These had been epileptiform. In five cases only were there 
adhesions of the pia mater to the convolutions, and in two of these the 
whole pathological appearances so resembled those of general paralysis 
that I think they had been instances of that disease, complicated by 
ordinary softenings in the basal ganglia. There was very marked 
atrophy, with or without softenings of the convolutions in twelve cases, 
or one-third of the whole number. Through atrophy, or adhesion of the 
pia mater, or disintegration, or the pressure of tumors, the convolutions 
were manifestly diseased in twenty-seven of the thirty-six cases, or seventy- 
five per cent. This gives so far a definite pathology to paralytic insanity, 
by showing that it is not merely through lesions of the basal ganglia and 
their reflex convolutional disturbances that it occurs, but through appre- 
ciable disease of the convolutions themselves, in three-fourths of the 
patients that die. I have no doubt that microscopic examination would 
have shown the convolutions affected in a still larger number of cases. 

The frequency of tumors was surprising. They were found in seven 
of the thirty-six cases. In most of them there was manifest convolutional 
secondary lesion, through pressure or irritation, in addition to the tumors. 
In one case a spiculum of bone projected into the pons from the base of 
the calvarium, setting up thickening and inflammatory action. The 
atrophy in two cases was of that kind which affected chiefly the white sub- 
stance in the centre of one hemisphere, leaving the gray substance of the 
convolutions like a crust round a holloAv space (like the case figured in 
Plate v.). There were recent hemorrhages in only three of the cases : 
and there were purulent deposits in one. 

It may be concluded, therefore, that gross brain lesions, wherever 
situated, tend to cause mental disease in two ways — first, by reflex or 
other irritation, or excitation of morbid convolutional action ; and, sec- 
ondly, by actual destruction, primary or secondary, of convolutional 
structure. 



LECTURE XI. 

EPILEPTIC INSANITY— TRAUMATIC INSANITY. 

The motor neurosis called epilepsy may exist in every form, and 
according to every definition, without being associated with such mental 
disturbance that it could be called insanity. Whether we hold epilepsy 
to comprise every motor spasm, even the slightest, or restrict it to the 
periodic recurrence of general convulsions accompanied by unconscious- 
ness, it may exist without insanity. But, on the other hand, in a very 
considerable proportion of cases, epilepsy has as its accompaniment 
mental disturbances, amounting often to insanity. And a very important 
form of insanity it is. Long before Dr. Skae classified mental diseases 
clinically, epileptic insanity was recognized and named. From the 
earliest times its mental accompaniments have increased the mystery and 
terror of epilepsy. When, added to the contortions and unconsciousness 
of that disease during a fit, there were afterwards developed strange 
hallucinations, terrible acts of impulsive violence, and striking religious 
delusions, we cannot wonder that a supernatural cause was almost 
universally believed in of old. No demon could by any possibility pro- 
duce more fearful effects by entering into a man than I have often seen 
result from epilepsy. 

The first great fact to be kept in mind, in regard to epilepsy in its 
mental relations, is that the frequent recurrence of epileptic fits for many 
years tends in some degree to impair the mental faculties, to dim the 
reasoning power, to twist or take the fine edge off the feelings, emotions, 
and sensibilities, to affect the memory, to lessen the self-control, and to 
change the " character," even where there is no actual insanity. If a man 
only takes a few fits in his lifetime, and they are far between, there may 
be no mental accompaniment whatever, except the unconsciousness at 
the time and the transient confusion after each fit. And, beyond a 
doubt, the occurrence of such rare fits is compatible with great mental 
power. Julius Csesar and Mahomet are said to have had such occasional 
attacks of epilepsy. 

When I speak of epilepsy causing insanity and mental symptoms, you 
must clearly understand that the whole series of symptoms, bodily and 
mental, may in some cases be the combined result of a general disturb- 
ance of function or of disease in the brain, neither the convulsions being 
the primary disease, nor the mania, but both being equally effects of the 
same cause. It is usual for the epileptic insanity not to follow at once 
the first appearance of the fits. Most commonly years elapse before it 
comes on. No doubt the more severe and the more frequent the fits the 
greater is the risk of insanity, but certain epileptics suffer merely a 
gradual mental clouding and diminution after years of epilepsy, while 
others have furious mania very soon after the first fits have appeared. 



EPILEPTIC INSANITY. 287 

It would seem as if certain cases of epilepsy from the beginning con- 
sisted essentially in their nature quite as much of a mental as of a motor 
instability and explosiveness. I do not agree with Hughlings Jackson 
that, in cases of iMtit mal and slight convulsions, the explosion, not 
finding vent in a motor form, is more apt to extend up into mental 
centres. There are some few such cases, but in my experience only a 
few. The theory is fascinating, but there is danger ill making too close 
an analogy between a mental disturbance and an ordinary motor convul- 
sion, and in regarding them as virtually the same thing, the one being an 
"explosion" in a "mental centre" and the other in a motor centre. I 
admit that such a view is most instructive as a hypothesis and help in 
making definite one's ideas, and in some rare cases of epileptic insanity 
seems to fit the facts exactly, and explain the apparently substitutionary 
character of the convulsion and the psychosis. But in nineteen cases 
out of twenty of epileptic insanity, the mental symptoms are not of the 
sudden explosive character at all, as we shall see, and they are by no 
means attended with unconsciousness or false consciousness, loss of 
memory, and want of power of attention. The theory of explosion 
assumes that you have a morbid energy developed in such brains that 
will act in some form, just. like a charge of gunpowder, which, if you 
obstruct the muzzle, will blow out the breach of your gun. 

Epileptic insanity, and by this T mean all the morbid mental effects 
associated with the disease, occurs in relation to the fits in six chief ways : 
(1) After them. This is on the whole the most common, and the mental 
symptoms then seen are essentially periodic and paroxysmal, like the 
motor convulsions. They follow usually within twenty-four hours of the 
fit or fits. If there have been a series of fits, they are much more apt to 
occur than after one only. (2) Before the fits. They usually show 
themselves a day or two, rarely three or four, before a fit is coming on. 
And in such cases, when the fit occurs, the mental irritability, suspicions, 
impulsiveness, or confusion, usually disappears at once, its place being 
taken by a stupidity, or in some cases by normal mentalization. This is 
undoubtedly a strange fact, but is abundantly seen. Our attendants in 
asylums can tell in this way when a fit is coming on in many of the epi- 
leptics under their care. The fit, like a thunderstorm, seems to clear the 
air. (3) Mental disturbance may occur, instead of the fits, taking their 
place, apparently coming on at the period when the fits might have been 
expected. This is rare, but very instructive. It is the epilepsic larvee, 
or masked epilepsy, of the French, and seems to favor Hughlings 
Jackson's explosion theory of epilepsy more than any other clinical fact 
observed in connection with this disease. (4) A slow, steadily progressing 
loss of memory and change of affection, a blunting of the finer feelings, 
and a permanent mental obscuration or tAvisting, those being often the 
very first symptoms present, growing more intense the longer the patient 
lives and takes the fits. This is, in fact, a dementia either from brain 
injury by the fits or from the natural advance through prolongation of the 
morbid brain state that caused the epilepsy. Most epileptics tend to 
become demented if they live long enough. The arrest of mental devel- 
opment, and the degeneration towards idiotic conditions seen in nearly 
all cases where epilepsy occurs early in life, come under this heading. 



288 EPILEPTIC INSANITY. 

(5) Some forms of chronic insanity take the place of the fits, which cease 
altogether. I have seen only four or five cases where this took place, and 
they all occurred at the termination of the reproductive period of life. 

(6) Epilepsy may begin in the course of chronic insanity of many years' 
duration, evidently through advance of disease from the mental into the 
motor centres of the brain. I do not mean a mere sporadic convulsion 
or series of convulsions, in the course of a case of recent or chronic 
insanity, such as I have described in that form of melancholia which I 
have called convulsive, or like those cases of alcoholic or syphilitic 
insanity in which convulsions play a part. I refer to those cases of 
chronic insanity, usually dements, who become epileptic, beginning to 
take regular periodic fits after being many years insane, and then going 
on taking them regularly. I have seen about a dozen such cases, and 
now have five such under my care. 

It will be observed that all these relationships point to a close connec- 
tion between the locus in quo of epilepsy in the brain and the seat of 
mental disturbance. The fact that they are related to each other in such 
various ways is the strongest proof of the nearness of their pathological 
seat. The experimental demonstration of a motor function in the convo- 
lutions seems to be strongly confirmed by all the clinical facts of epileptic 
insanity. Hereditarily ordinary insanity and epilepsy are closely allied. 
The son or daughter of an epileptic is just as likely to be idiotic, weak- 
minded, drunken, or insane, as to be epileptic ; and certainly the children 
of families with a strong insane heredity are very commonly epileptic. 

The actual mental symptoms caused by, or associated with, epilepsy 
vary considerably, as we shall see from the cases that will be related ; but 
there is a certain type of psychosis so common as to be almost character- 
istic. Two words express its most marked characteristics, irritability and 
impulsiveness. I suppose one may look on these as representing a morbid 
state of nutrition and energizing of the brain convolutions, whereby there 
is a morbid energy evolved and a want of inhibition to control it. The 
epileptic psychosis may exist in every degree from the merest excess of 
irritable temper up to the most dangerous homicidal impulses and acts. 
I have seen epileptic insanity take the form of a more acute maniacal 
condition than almost any other insanity. Before the days of the 
bromide of potassium, and its regular use in the cases of most epileptics 
in asylums, no patients were so troublesome or dangerous. There is no 
form of insanity that, outside asylums, is more frequently the cause of 
murders except, perhaps, the alcoholic. Hence its medico-legal importance 
to medical men and jurists. It depends much on the strength and intel- 
ligence of the medical evidence whether an epileptic murderer is hanged 
or sent to Broadmoor. If a man has been subject to regular epileptic 
fits, and commits a murder in an impulsive or motiveless way, then I 
think the presumption would be very strong that he was not fully 
responsible for his actions. No prejudice or want of knowledge on the 
part of judges or juries should prevent a medical man from giving clear 
evidence on this point. A murder by an epileptic should usually be 
looked on as being as much a symptom of his disease as larceny by a 
general paralytic. 

A certain religious emotionalism of a strong and usually perverted 



EPILEPTIC INSANITY. 289 

kind is often present in epileptics. We have now a lad (C. W.) in whose 
anti-bromide, and therefore natural, epileptic clinical history it was a sure 
prelude to a fit, or series of fits, that he took his Bible, read it continu- 
ously, and when spoken to would answer fiercely — " Don't trouble me, 
I'm a good man, I'm a servant of God." The day after, he would be 
walking up and down, striking any patient or anyone else who ventured 

to speak to him, replying maniacally — "You're a d d liar! Don't 

insult me!" if one remarked to him it was a fine day. That night he 
would have one or two fits, and would be stupid and much inclined to 
masturbation. Next day he would keep his bed, and after a day or two 
would get up and go about as usual. The bromide treatment, in doses 
of twenty grains three times a day, has utterly destroyed the typical 
psychosis as well as diminished the number of fits, for he is now a mild, 
industrious, slightly weak-minded young man, who does what he is told, 
and only takes a fit every six months, instead of a series of them every 
month. 

As illustrating epileptic irritability not reaching this maniacal stage, 
look at those two women, G. X. and G. Y. The one, G. X., rages at 
her attendant, calls her a murderess, affirms that she has given her no 
food to-day (she has just had her dinner, eating half of it and throwing 
the remainder at the attendant), and that she has tried to poison her 
often. Nothing you can say to her but will rouse anger. No remark, 
however mild, but will excite a storm of scolding. No soothing influence 
will mollify her in the least degree. She tries to imitate your voice. 
She is sarcastic, abusive, and threatening by turns, as I demonstrate the 
failure of the psychological experiment of a soft answer being able to 
turn away wrath. By the way, that psychological aphorism is more 
applicable in dealing with the insane than almost any other class of 
human beings. It stands me in good stead many times every day; and 
if I could only practise it always myself, and get my attendants to prac- 
tise it, we should save many rows, and avoid on many occasions the use 
of physical force. But I am bound to say it altogether fails sometimes, 
and notably in this patient, and in other epileptics. But just try the 
opposite tack, and contradict her and tell her sharply that she is an 
unreasonable woman, who is talking nonsense and acting like a fool. 
How this aggravates all her symptoms ! She shouts, and at once threatens 
personal violence. "Never contradict or attempt to reason with an epi- 
leptic when excited," is an axiom in asylums. I wish we could get our 
attendants always to practise it. Now, this woman had a fit two days 
ago, and by to-morrow her irritability will have passed off, and she will 
be a quiet, civil, and agreeable woman. 

The next patient, G. Y., is in much the same general condition of 
morbid irritability. She sings a psalm tune in a noli me tangere tone of 
voice. When I ask her mildly what tune that is, she denounces me as 
a hypocrite and a scoundrel, says I am of the seed of the devil, and that 
she is one of God's, people, and of the seed of Israel. This delusion 
recurs whenever she has fits. She describes visions she has, in which she 
sees Jesus Christ and tlie prophets. At times she lias the hallucination 
that she is surrounded by flames, and sees eyes like fiery balls ghiring at 
her. Slie is almost never amiable, is subject to uun-bid suspicions and 

19 



290 EPILEPTIC INSANITY. 

aversions to certain people. Her social instincts Lave been almost up- 
rooted by her disease. 

In both those cases the bromide has been tried, and failed to do good. 
This has partly resulted from the fact that the trial was imperfect, for 
they both believed it was poison given to do them harm, resisting and 
refusing it, and partly because the epilepsy they are both subject to is 
nocturnal. This is never so subdued by the bromides as the fits taken 
by day, and the epileptic psychosis associated with nocturnal epilepsy is 
also unamenable to the good effects of the drug. Epileptic insanity is 
not nearly so common among women as men, whatever may be the case 
with uncomplicated epilepsy ; and when it occurs it is less benefited by 
the bromides in most cases. ^ 

Next, let us take a case of typical epilepsy and typical epileptic in- 
sanity in a man, a patient that illustrates a great many clinical facts of 
an instructive kind : 

H. A. was said to have been thrown from his palanquin in India at 
the age of seventeen, and to have alighted on the left side of his head. 
He did not suffer much at the time, and had no epileptic fits till seven 
years afterwards when home on furlough. Yet on this slight post-hoc 
the epilepsy was put down to the fall in India. Relatives will always 
assign some cause for such a disease. There have been neuroses and 
mental disease, but no epilepsy, in the family. The fits began in March 
one year, and were numerous and severe. They usually came on about 
every month, but sometimes every day or two. In September following 
he had a severe maniacal attack, for which he was sent to the asylum. 
It was accompanied by unconsciousness, and a constant rotating motion 
from left to right, the eyes staring in a fixed, glassy way. His condition 
was, in fact, more a stupor with motor restlessness. This is not an 
uncommon kind of epileptic psychosis. This lasted for ten days, and he 
then got well. He had a pain in the left side of his head, especially 
before the fits, and his left arm in the fits, especially in the clonic spasm, 
twitched more than the right. It was thought that those things pointed 
to a depression of bone, or some such local irritation, at the part where 
he fell. The late Mr. Syme trephined the bone at the spot, taking out a 
circle about the size of a halfpenny. A "very questionable alteration" 
in the bone was thought to be detected. "No alteration was detected on 
microscopic examination." In a week he had a maniacal attack, without 
having any fits, during which he was most violent — shouting, struggling, 
recognizing no one. To prevent him injuring the wound he was kept in 
bed by a number of sheets and skeins of worsted. This lasted for a 
fortnight, when he got well again. For three months he kept well, and 
was discharged from the asylum "relieved," having no fits for four 
months after the operation. He then became depressed in mind and 
emotional, weeping much. This, as a temporary phase of epileptic 
psychosis, is not uncommon. He then had several fits, which were 
followed within two days by an acute attack of mania, with frenzied 
violence. He was put in restraint in the sheets again, as his scalp was 
tender, and he threw himself against the walls of the room. As he got 

' For the exact statistics, see Journal of Mental Science for October, 1868. 



EPILEPTIC INSANITY. 291 

out of the unconscious maniacal .^tate he was irritable, unreasonable, and 
complained of everything. Nothing or nobody could please him. This 
was the very opposite of his njjitural disposition, which was most consid- 
erate and gentlemanly. In four months after this, he had a recurrence 
of the fits and a maniacal attack. He then took the fits occasionally 
during the next six months without there being any mania. But he was 
liable to sudden short attacks of epileptic psychosis, during which he 
would suddenly strike out at those near him, or his expression of face 
would change and become furious, while he would stare at any one beside 
him, and shout fiercely — ^' What the devil do you mean, sir?" This state 
would occasionally come on of itself without any exciting cause, but would 
sometimes be set up by contradiction, or when he saw anything done that 
he disapproved of. I remember being one of a party of four playing 
whist, he being one. We were playing quietly, not a word being said, 
when he suddenly let go his cards, stared at his partner with his eyes 
"rolling out of his head," and, with a damnatory exclamation, sprang at 
his throat over the table. He was seized, held gently on the sofa for a 
few minutes, came to himself, asked what had been up, and we went on 
with the game. He remembered nothing about what had occurred. This 
is what Hughlings Jackson would call an attack of "mental epilepsy." 
He then began to take the fits, about one every week, nearly always 
during the day. He was subject to various sensory neuroses, as most 
epileptics are, such as sensations of pins and needles in his limbs, a feel- 
ing as if there were twitchings in his head, especially after going to bed 
and before going to sleep, numbness in his left thumb, and tic in his right 
eye and temple. 

All sorts of treatment were tried for the disease — morphia by mouth 
and subcutaneously, sulphates of zinc and copper, severe purgation, 
counter-irritation, colchicum, and alkalies, but while he seemed to be a 
little better for each drug, he soon was the same as ever. Occasionally 
he would pass two months without a fit, except perhaps a few attacks of 
petit mat. In 1865 he was put on the bromide of potassium in ten- 
grain doses three times a day. In a month he said he felt much better 
in health, had no nervousness, and little of the twitching feeling. His 
general health became better. For five months he took this, and had five 
fits in that time, only one of them being severe, and he had no maniacal 
excitement. The dose was then doubled, that is, he took twenty grains 
thrice a day. For one hundred days after that he had only two attacks 
oi petit fnal, then he had a slight fit. He kept so well in mind that, 
after a year of the bromide treatment, he left the asylum on probation, 
being charged to go on with the medicine. He stayed at home for six 
months, and did well. Then he began to take the fits rather more fre- 
quently, taking about two or three in the month of a sliglit character. 
He tlien came back to the asylum voluntarily, not being maniacal. The 
fits almost always come on just after waking or during sleep about 5 A. M., 
thus clianging their character from day to night fits. Bromide acne used 
to trouble him, and he would on that account stop the medicine, but he 
always had a fit witliin three days after this. 

For two years lie continued to take fits about every month or six weeks, 
but Avas never maniacal. Taking the fits in the morning, he entered into 



292 EPILEPTIC INSANITY. 

the amusements of the asylum, playing billiards, cricket, dancing, etc. 
Of one thing he never could be made to realize the importance, and that 
was the risk he ran in dangerous places on account of a fit suddenly coming 
on. This was like all epileptics. He would constantly stand near the 
fire, or walk near steep places. When at a picnic at the Falls of the 
Clyde once, he went quite near one of them to look over. When warned 
of the risk, he coolly remarked that life would not be worth having if he 
were always thinking of the risks from a fit. It seemed to me the 
bromide treatment not only lessened the irritability of temper and the 
number of maniacal attacks, but that it prevented the mental degenera- 
tion in feelings and manners which long-continued epilepsy is apt to cause. 

He had a severe fit and a maniacal attack after it in 18T0, for the first 
time for four years, during which he was most violent, sang at the pitch 
of his voice, and knew nobody. During this paroxysm he cut his hand 
severely with the glass in breaking a window. He had no severe maniacal 
attack after that for two years, though taking the fits. In September, 
1872, he took a fit by day when standing with his back to an open fire ; 
he fell backwards, and burned himself most severely in the gluteal region, 
causing a sore of nine inches in diameter. For nine months after this, 
while the sore was discharging much pus, he had no fits, though taking 
no bromide. This I have seen very frequently in epileptics. Then his 
fits began again, but were very infrequent. His lungs then began to be 
afi"ected. In about a year the wound healed, and then for the first time 
since the burn he had a mild maniacal attack. The lung disease gradually 
progressed, and he died in two years and a half after the burn. He had 
not a trace of mania and very few fits, for the last nine months of his 
life, during which his lungs were very far gone. 

On 2^ost-morte7n examination, the dura mater was found adherent to 
the lower surface of the circular hole made in trephining the skull-cap, 
and was adherent below to the arachnoid and pia mater. There were 
no spicul^e or thickenings of the bone towards the brain anywhere. On 
the left side of the spot operated on the pia mater was adherent to a brain 
convolution. The arachnoid was slightly milky, and there was consider- 
able vascularity in the brain substance, with some little perivascular 
atrophy. Otherwise the brain was normal, and the medulla was not 
congested, though the vessels were enlarged. 

The condition of the brain did not confirm the idea of an injury from 
the original fall, and threw no light on the cause of the epilepsy. 

In this one case you see there existed at difi"erent times, and under 
different circumstances, epileptic irritability ; epileptic mania with and 
without consciousness, the latter at times being; wildlv delirious and in 
the highest degree dangerous to the patient and those near him ; epileptic 
impulsiveness of action and violence ; epileptic stupor ; epileptic de- 
pression ; epileptic false consciousness ; epileptic automatism ; the charac- 
teristic epileptic want of realization of the dangers to which the liability 
to take the fits any moment exposes the patients ; epileptic sensory neu- 
roses ; the temporary improvements that counter-irritation and new modes 
of treatment are apt to produce in epilepsy ; the decided relief of many 
of the symptoms by the use of the bromide of potassium, which yet does 
not cure, and acts best at first ; the cessation of the fits and of the ten- 



EPILEPTIC INSANITY. 298 

dency to maniacal outbursts when serious bodily diseases come on ; lastly, 
the present unsatisfactory pathology of the disease was also illustrated. 

Epileptic insanity should be studied along with the symptomatological 
class of impulsive insanity, with which it is very nearly allied in symptoms 
and heredity. I have already alluded to the case of E. L. (p. 238), so 
many of whose children died of convulsions, and whose brother is an 
epileptic patient in the asylum. It is also closely allied to somnam- 
bulism. Epileptic insanity proper is accompanied by, and complicated 
with, some of the most extraordinary and irregular mental phenomena. 
I have a man, H. B., who at times has hallucinations of smell, fancying 
the air is polluted round him by putrid meat ; another, H. C, who 
affirms that we cause itching and formication of his skin, he scratching 
himself violently after fits sometimes. I have known a " fit of itching" 
come on him instead of an epileptic fit. We have several epileptics who 
receive messages from the Deity after fits. I have a woman, H. D., who, 
before and after a fit, and while she is taking it, for she does not lose her 
consciousness, imagines she has two heads, and that one is under her own 
control and the other under the control of an enemy. In her case the 
fits are unilateral at first. I have a man, H. E., in whom an aphasic 
attack comes on and lasts for periods from one hour to three days, instead 
of epilepsy, he being meanwhile i-ational, cheerful, and industrious, and 
writing on paper anything he has to say or answers to questions. 
/ Suicidal impulses are not common in epileptic insanity. When 
present, they usually result from hallucinations of hearing voices telling 
the patient to commit the act. I had lately a well-marked case of this 
sort, H. F., a man aged thirty-nine when he was sent to the asylum, who 
had been subject to epilepsy for several years, and had often been maniacal. 
During one of his attacks he had bitten off his father's nose, under the de- 
lusion that he was calling him bad names. When well he was attached 
to him. He had exposed himself to some of the strongest causes of brain 
disease, for he had drank hard (epileptics very often do), had contracted 
syphilis, and exceeded with women, and, when a soldier in India, had 
been exposed to the sun and had sunstroke. When admitted he was very 
violent and homicidal. He heard voices, as if it were his fellow-patients 
calling him foul and offensive names, such as ^' thief," "scoundrel," 
"beggar," etc. He would often assault savagely men who were not 
speaking to him at all. He took the fits, which were of the ordinary 
character, about every fortnight. The hallucinations and homicidal 
tendency were usually worst before the fits, but he was ahvays irritable, 
sullen, unsocial, and had a very strong and uncontrollable craving for 
drink and tobacco. He was put on the bromide of potassium in twenty- 
five-grain doses three times a day. At first it seemed to have no effect, 
but after about six months he became mentally changed for the better. 
He got chatty, amiable, and industrious. He had occasional outbursts 
of sullenness and irritability, but seldom was violent. He had the liallu- 
cinations of hearing very often, but he said he disregarded them, and 
latterly said lie had got liimself to believe by reasoning that they were 
"voices" only, and not the words of actual men. If he took liquor, ho 
was always worse in temper and conduct, and was apt to have morbid 
suspicions and hallucinations badly afterwards. At times he would 



294 EPILEPTIC INSANITY. 

request to be put into his bedroom alone, to be quiet and out of the way 
of the temptation of assaulting his fellow-patients. After being in the 
asylum two years he had a short paroxysm of mania, and broke open his 
room shutter and got out, but was recaptured before he went away. He 
afterwards said that the voices had been tellino; him to go and throw him- 
self over the Dean Bridge, which is the chief temptation to dramatic 
suicide in Edinburgh. He improved much after that, and took no 
epileptic fits ; on one occasion, for eighteen months, never needed seclu- 
sion, got the parole of the grounds, and went into Edinburgh so see his 
relations occasionally. Xo suicidal attempt was ever thought of by me 
in his case. The fits had become slightly more frequent, however, in 
spite of the bromide. When out one day he went into town for a walk 
with two fellow-patients, was perfectly cheerful, and even. jovial ; met his 
brother, and chatted pleasantly with him, saying he would be out again 
"next Saturday." On his way home he said to his companions that he 
was going to a urinal, went down a by-street, and then as straight as he 
could go he made for the Dean Bridge and threw himself over, killing 
himself instantly. This was two years after the time he said the voices 
told him to do so, and for twelve months before he might have gone and 
done so any day, so far as any restraint in the asylum was concerned. 
On post-mortem examination, I found the pia mater over the whole 
vertex of the brain strongly adherent to the convolutions, and the ven- 
tricles granular, just like a typical case of general paralysis. In fact, I 
never saw any case of that disease with those pathological appearances 
much more marked. 

The homicidal acts of epileptics are done under the most various cir- 
cumstances, are widely different in character in different cases, and even 
in the same case at different times, sometimes are done reasoningly from 
conscious insane motives, sometimes apparently, but not really reason- 
ingly, because without consciousness or memory. An epileptic may 
scheme to do an act of insane violence and try to conceal it carefully 
afterwards. They are most apt to take unfounded dislikes, especially to 
their relations and those near them. The conscious anger will pass into 
the epileptic unconscious mania in a moment sometimes. One of the 
most extraordinary things I ever knew was this : A young epileptic, 
H. G., who was very friendly with me when he was well, used to dislike 
me very much when excited after fits. • On one occasion the attendant 
found him and another patient contriving to make up a weapon, with 
which to assault me or the chief attendant, out of a stocking which the 
epileptic had taken off, put a stone in the toe of it, tied a string about this, 
and had then slipped it up his sleeve till he should have a chance of using 
it. When he got out of the epileptic mental condition, he was astonished 
when told about this, and said he had no recollection of it whatever, 
which I believed to be true. The combination with another patient, and 
the purposive combined preparation of a lethal weapon, all in a state of 
epileptic unconsciousness, I could not have believed possible had I not 
seen them in that patient. Suj^posing this man had not been in the 
asylum and had combined with another in preparing a weapon, waiting 
for an opportunity, and had committed murder : and then supposing a 
doctor had gone into the witness-box and given evidence that the murderer 



EPILEPTIC INSANITY. 295 

^as quite irresponsible on account of his being in a state of epileptic 

insanity, and quite unconscious of his acts at the time, with what lofty 

5Corn would the judge have put aside such evidence as being inherently 

[incredible ! With what dogmatic assertion the newspapers would point 

such an example of a medical man trying to defeat justice and screen 

criminal ! What lively ridicule the journals would have poured upon 
evidence so "opposed to common sense and to law!" And all this 
because a fact of nature and of disease had been brought out before those 
who were ignorant of the whole subject. 

Pathology. — As regards the pathology of epileptic insanity, it is, like 
the pathology of epilepsy, as yet very obscure. I have met with innu- 
numerable brain lesions of almost every kind in different cases, and, on 
the other hand, I have most carefully examined the brains of many 
epileptic insane persons, and have found no special lesion or abnormality. 
I have found the following amongst other lesions, viz., spicula of bone 
from the skull-cap and membranes pressing into the convolutions, 
apoplexies, destructive lesions of the brain of all kinds and in all places, 
embolisms, fatty and otherwise, adhesions of the pia mater to the convo- 
lutions, the marks of traumatic injuries of all kinds and in all places of 
the brain, unequal hemispheres, and congestion of all sorts and in all 
places. I have tried my best to confirm Schroeder van der Kolk's 
observations as to the medulla and pons being always congested or 
diseased in epileptics. I have certainly failed to do so, and do not 
believe that it is the case. The general result of my pathological obser- 
vations is, that any source of irritation in a brain of a certain quality 
may cause epilepsy, but that an irritation to the motor area of the convo- 
lutions is infinitely more apt to cause it than one anywhere else. The 
coordination of the convulsions, the unconsciousness, and the breathing 
difficulties of the actual fit, may arise in the medulla, but the real origin 
of the convulsions is usually higher up in the brain. To have epilepsy 
we must have an inherent motor instability in the convolutions, just as 
we must have essential mental instability in the convolutions in order to 
have insanity. The epilepsy is an occasional dynamical disturbance, 
that may be the result of a constant pathological lesion, or of an 
inherently morbid brain constitution. It is a remarkable fact in epilepsy 
that one hemisphere of the brain is in nearly all cases found considerably 
heavier than the other, and that in by far the majority of the cases of 
infantile paralysis or unilateral development, where one hemisphere 
of the brain is larger and more perfect than the other, such patients are 
subject to epileptic fits. 

Treatment. — As to the general treatment of epileptic insanity, it is 
that of epilepsy with that of mania superadded ; and with special pre- 
cautions to combat the special dangers I have described. Give X\\e 
bromides regularly and steadily as you give food to your epileptics. 
Find out the dose for each case that will saturate but will not bromize, 
which will be from forty to seventy grains a day in difierent cases. J lalf 
bromide of potassium and half of sodium, with one or two minims o'i 
liquor arsenicalis to each dose, makes a capital combination. It can bo 
given for years. I have known it continued noAV for fifteen years in a 
case, witli immoiise benefit and no harm all that time. Some few cases 



296 EPILEPTIC INSANITY. 

will not be benefited at all, but four-fifths will be so more or less, and 
one-half will be benefited very much, while one-fourth will be so much 
benefited as to be practically cured, so long as they are kept under treat- 
ment. Its use will very often save epileptics being sent to asylums. Any 
physician to an asylum who does not keep most of his epileptic patients 
continuously under the influence of the bromides deliberately disregards 
one of the best proved therapeutic facts, for I have proved by experiment 
that he can reduce the fits to one-sixth, taking all the epileptics in an 
asylum together, and practically cure some cases, while most are improved 
mentall3^ Any physician out of an asylum who has an epileptic to treat, 
and sends him into an asylum without trying the efi"ect of the bromides, 
does not, I think, give his patient the best chance known to science. 
Many patients will at times become bromized, but the white tongue, 
mental hebetude, and slow muscular movements of this conditipn can be 
easily seen in time before much harm is done. Intermittent bromide 
treatment is of little or no use. It must be continuous to do much good. 
Why the bromide does good to epileptics is as yet not ascertained in an 
absolutely definite scientific way ; but my belief, founded on a most ex- 
tensive experience of its use, is that its therapeutic effects are closely 
connected with its physiological actions of (1) diminishing the irritability 
of nervous tissue; (2) lessening the blood-pressure in the capillaries; 
(3) diminishing the sexual desire and the reproductive power; (4) pro- 
ducing a slowness in the mental operations allied to the phlegmatic tem- 
perament. In addition to the bromide treatment, dietetic regulation, the 
avoidance of surfeits, plenty but not too much exercise, life in the fresh 
air, no excitement that can be avoided, and no alcohol, are all useM. I 
have several epilej^tics who will almost certainly take fits or become irri- 
table if they go to a dance or get two glasses of whiskey. Blisterings and 
setons do good in some cases, while ergot and conium, especially if com- 
bined with chloral and the bromides, will control outbursts of excitement. 

The moral treatment must be soothing but firm, with no arguing, 
sharpness, imperiousness, or useless verbal contradiction. There is a 
procedure in the management of cases of epileptics subject to maniacal 
attacks that I look on as of the greatest importance as tending to prevent 
attacks of mania coming on. It is founded on the natural history of the 
disease. After an epileptic fit of the graver kind, a patient is always 
necessarily unconscious at first, then stupid and confused, and then sleepy, 
and if he is favorably situated he goes off into a very sound sleep. This 
seems to me nature's mode of restoring the disturbed cerebral circulation 
and recuperating the exhausted organs. Even after the sleep, most epi- 
leptics feel tired for a time. Now, by carefully giving an epileptic the 
chance of sleeping after his fits, by putting him on a sofa and darkening 
the room, we aid nature in her efforts to get over these effects. When 
the patient will not sleep, but shows signs of being restless and excitable, 
give him twenty or thirty grains of chloral, with a drachm of the bromide, 
and put him to bed in a dark room. The chances are he will sleep soundly 
and long, and will wake up all right. I have seen this plan succeed in 
apparently averting an outburst of epileptic mania dozens of times. 

As regards the results of treatment, they are in one way unsatisfactory 
from the risk of relapse, and in another way satisfactory, because the 



EPILEPTIC INSANITY. 297 

patients may go home from asylums and earn their livelihood, and enjoy 
their liberty for long periods, often for life, if they will persevere in suit- 
able treatment. A patient recovered from epileptic insanity may, while 
he is well, be quite as well as a Avoman recovered from puerperal insanity. 
Our results in the Morningside Asylum for the ten years 1873-81 have 
been that out of one hundred and twenty-eight cases admitted, thirty-one, 
or twenty-four per cent., have been discharged recovered of their epileptic 
insanity, and with the epilepsy itself greatly modified. Most of these 
have been able to remain at home. And it must be remembered that the 
cases sent to asylums are the worst cases of the disease. The milder 
cases with infrequent attacks are often treated at home very satisfactorily. 

Local Prevalence. — Epileptic insanity prevails very differently in 
different parts of this country. In the southern agricultural counties of 
England, where wages are low, life is stagnant, food is not too abundant, 
and beer is almost universally used as a part of the dietary, epileptic 
insanity is unusually common — standing over eleven per cent, of all the 
admissions, and in some individual counties forming about one-fourth of 
all the inmates in the county asylums of those counties. This includes 
the epileptic idiocy and imbecility, as well as the cases where the epilepsy 
arose later in life. In such parts of the country the former kind of epi- 
leptic insanity prevails much more than the latter. In the better-off 
mining and manufacturing counties, such as Durham, Glamorgan, Staf- 
ford, etc., and in some counties of mixed population, such as Sussex, the 
proportion of epile23tic insanity in the admissions is only about five per 
cent. Clinically, epileptic insanity is more acute and typical in those 
districts. In the large cities of England it holds an intermediate place, 
forming about eight per cent, of the admissions to the asylums of those 
cities. In Scotland it prevails to a less extent than in England. In the 
admissions to the Koyal Edinburgh Asylum, whose pauper patients are 
drawn entirely from a city population, only four per cent, have labored 
under epileptic insanity during the past nine years, and only seven per 
cent, of our present inmates are of this class. In other parts of Scotland 
it is still more infrequent. 

(The following "is the general summary and conclusions of my experi- 
ments made in 1867 to determine the precise effects of the bromide of 
potassium in epilepsy and epileptic insanity :) 

Twenty-nine cases of epilepsy of old standing, all having the same diet, and subject 
to the same conditions, were subjected to systematic treatment by bromide of potas- 
sium, after their normal condition as to lits, weight, temperature/general health, and 
mental state had been ascertained and noted. 1 gave them gradually increasing doses 
of the medicine, from live grains up to fifty grains, three times a day, and the" treat- 
rnent was continued for thirty-eight wcelcs,' every essential particular in regard to the 
disease and their bodily and me'ntal condition being noted every week during that 
time. 

The total number of fits taken by the patients fell gradually under the use of the 
medicine to one-sixth of their average number without medicine. 

The fits taken during the day were lessened to about one-twelfth, and those taken 
during the night to about one-third of the previous number. 

The reduction in the fits was not uniform in all the cases. In one ca e it amounted 
to twenty-four thousand per cent., in one-half of them to more than one hundred per 
cent., and in five cases there was no reduction at all. 

In one-fourth of the cases the tits were uuich less severe, in some beiui;- less severe, 
while us frequent us before. 



298 TRAUMATIC INSANITY. 

In one-fourth of the cases, the patient's mental state was very greatly improved. 
ISTervous and mental irritability and tendency to sudden violence were wonderfully 
diminished in those cases, and they were the worst of the patients in that respect. 

Attacks of epileptic mania were diminished. In some cases the mental state was 
improved, while the fits remained as frequent as ever. 

The majority of the patients gained considerably in weight while the doses were 
under thirty-five grains, three times a day. Their aggregate weight was greater at 
the end of the thirty-eight weeks than it had been to begin with, though it began to 
fall after thirty-five-grain doses had been reached. 

The patients' average temperature fell somewhat until they got to fifty-grain doses 
thrice a day. 

The pulse gradually fell about seven beats up to forty-grain doses. After that it 
rose, but not up to its usual standard without medicine. 

None of the patients suffered in their general health except five. All the others 
were benefited in some way. 

The ill eflects produced by the medicine in those five cases were torpor of mind and 
body, drowsiness, increase of temperature, loss of weight, loss of appetite, and in three 
of them slight double pneumonia. 

The cases most benefited by the drug were very various as to the causes, number, 
and character of the fits, age, and in every other respect. On the whole, the cases 
who took most fits benefited most. 

The cases in whom the medicine had ill efl:ects had all taken fits from childhood, 
were all very demented in mind, and took more than one fit per week, but seemed to 
have nothing else in common. 

The diminution of the fits and all the other good effects of the medicine reached 
their maximum in adults at thirt^^-grain doses, three times a day, while ill effects were 
manifested when thirty-five-grain doses, three times a day, were reached. 

There seemed to be no seriously ill effects produced in twenty of the cases by fifty- 
grain doses of the medicine, thrice a day, continued for ten weeks. 

When the medicine was entirely discontinued for a month in all the cases, the 
average number of fits increased in five of the cases benefited to or beyond their 
original number, in thirteen cases they remained considerably less. 

The average number during that time was a little more than one-half the number 
of fits taken before the medicine was given, and the greatest number of fits occurred 
in the second week after the medicine was discontinued. 



TRAUMATIC INSANITY. 

A few cases of mental disease are caused by blows on the bead, falls, 
and other traumatic injuries to the brain. Sunstroke also causes in- 
sanity, and the general mental symptoms of traumatism and sunstroke 
are apt to be alike. No doubt, sunstroke gets the credit of far more 
insanity than it produces. Few Englishmen become insane in hot 
climates, in whom that cause is not assigned. My experience is that 
traumatic insanity is to be found in two forms. The first form is the 
more characteristic type of the disease. It is accompanied by motor 
symptoms, either in the shape of speech difficulties, slight hemiplegia, 
general muscular weakness, or convulsions. Usually in such cases there 
are, in addition, sensory symptoms, such as cephalalgia, vertigo, halluci- 
nations, a feeling of confusion and incapacity for exertion of any kind, 
mental or bodily. The mental symptoms are usually a form of melan- 
cholia at first, tending in time towards an irritable and sometimes impul- 
sive and dangerous dementia or delusional insanity. In my experience, 
such cases are all absolutely intolerant of alcoholic stimulants, a very 
little of which will always make them maniacal, and often very dangerous 
and even homicidal. Many of them have a craving for stimulants, too, 
which they indulge, and which aggravates all these symptoms. It is 



TRAUMATIC INSANITY. 299 

surprising what a number of the traumatic cases are complicated with 
alcohol, in having been addicted to drink before these accidents, or taking 
to it after. Over one-half of my cases were so complicated. In either 
case, wdiether a drunkard falls and injures his brain and becomes insane, 
or whether a man takes to drink and becomes insane after an injury, the 
alcohol aggravates the mental symptoms, and tends more strongly tov,^ards 
incurability than mere uncomplicated traumatism. 

A few cases become ordinary epileptics. I have tAvo epileptics in the 
Royal Asylum now who have large depressed fractures, and I have seen 
several more on the post-mortem table. In one there had been a fracture 
above the ear, where the bone, membranes, and brain all adhered by an 
old inflammation. I have seen three patients now, in whom the motor 
symptoms were so exactly those of general paralysis that I diagnosed 
them as such, but they turned out to be non-progressive, though not 
curable paralytic cases ; and now, after over ten years, they are alive, 
and no worse than at first. One man, H. H., fell off a ladder, and 
fractured the base of his skull, was unconscious for long, and seemed 
afterwards to become a true general paralytic from this cause, but his 
symptoms did not progress. Another, H. I., a drunkard, received an 
injury to his head, was unconscious, and seemed to become mentally and 
bodily a most typical general paralytic, but the motor symptoms never 
progressed. As I mentioned, traumatism is one of the rare causes of true 
general paralysis. I had one such case that w^as caused by a raihvay 
collision, but then the man, after the accident, attempted to study and 
enter a profession wdth a weakened brain and an impaired memory. 
Within three years he became a general paralytic, and died of the disease. 

Usually the motor symptoms of traumatic insanity are non-progressive, 
or very slowdy so. But they do not always manifest themselves at once 
after the injury. I had one patient, H. L., who was not made uncon- 
scious at all by the blow of a piece of wood falling on his head, but who 
gradually in three months got weaker on one side, as well as being 
muscularly weak all over, and also mentally impaired in memory, energy, 
and volitional powder. He was also very irritable. 

Certain very interesting cases have been recorded of insanity directly 
following fractures of the skull, with consequent pressure on the brain, 
wdiich were cured by trephining or raising the depressed bone. One of 
the most striking of these was publislied by Dr. Charles Skae.^ It was 
that of a miner who received a depressed fracture of the skull about three 
inches above the left extremity of the left eyelid, w^as unconscious for four 
days afterwards, then went to w^ork, but within a fortnight exhibited a 
change of disposition and habit. Instead of being a sociable, merry, 
good-natured man, fond of his wdfe and children, he became at first 
irritable, moody, unsocial, and suspicious, and then excited and danger- 
ous, and then acutel}^ maniacal. He was sent to the Ayr Asylum, and 
two months after admission, during which time he had not improved, an 
operation was performed by Dr. Clarke Wilson, by which the depressed 
portion of bone was removed. A gradual improvement in mind took 

^ Journal of Mental Science, vol. xix. p. 552. 



300 TRAUMATIC INSANITY. 

place week by week after this, until in a short time he was as sociable, 
lively, and cheerful as ever, and has continued so ever since. 

Such cases are very suggestive of thought and inquiry as to the pos- 
sible reflex and direct irritations that may be the causes of mental disease 
in many cases, and they clearly show that the dynamical brain disturb- 
ance which we call insanity may sometimes originate in special points of 
local brain irritation. 

The condition of the urine as to sugar and albumen should be carefully 
tested in all traumatic cases. Where sugar exists there is room for grave 
suspicion of mischief to the pons near the floor of the fourth ventricle, 
though this can scarcely be diagnosed with certainty in this way. 

Some cases of idiocy result from injury to the brain by the forceps 
during delivery, and I have two now in the Royal Asylum resulting from 
falls on the head in early childhood. 

The other and less distinct class of traumatic cases are those in whom 
an injury to the brain acts as an exciting cause of an ordinary attack of 
insanity in a person predisposed to the disease — in fact where traumatism 
acts like a moral shock. As the result of a bout of drinking or some 
such disturbing cause of brain action after traumatism, I have seen attacks 
of mania and melancholia in patients from which they recovered perfectly ; 
and, on the other hand, I have now under my care several cases of ordi- 
nary dementia, and one of chronic mania, and one of delusional insanity, 
all incurable, and originating in traumatism, but without any motor 
sensory signs, and without progression of symptoms. I once saw a 
young man, H. M., of nineteen, who had an attack of ordinary acute 
mania just after being in a railway accident, and presumably caused by 
it, but by which he had not been made unconscious, or even stunned. 

I have now a case of suicidal melancholia, H. M. A., set. 46, resulting 
directly from an injury to his head through a piece of stone falling on it 
from a height of ten feet, and then his falling twenty feet on the back of 
his head ofi" the scafibld on w^hich he was working, cutting the skin over 
the occiput, but neither injury causing prolonged unconsciousness. This 
occurred three months ago, and ever since he has been able to do no work, 
has suffered from a dull feeling in his head and much pain in his back. 
His mental condition became gradually depressed. His attention was 
concentrated on his ailments until he was quite melancholic. He became 
suicidal, fancied he passed only blood from his bowels, which was a de- 
lusion ; and that his food did him no good, he being fairly nourished. 
There are no motor signs, and his temperature is normal, the reflexes 
being also normal, but he does not sleep. He gradually improved under 
treatment, until he became w^ell in mind and body and able for his work. 

Prevalence of Traumatic Insanity. — We have had twelve cases 
of traumatic insanity and the insanity of sunstroke sent to the Royal 
Edinburgh Asylum in the past nine years, which is only one-third per 
cent, of the admissions. Accidents to the head do not loom largely there- 
fore in the production of the insanity of the world. 



LECTURE XII. 

SYPHILITIC IlSrSANITY— ALCOHOLIC INSANITY. 

The mental as well as the bodily symptoms of brain syphilis have 
attracted more attention on the Continent than in this country, though 
of late years a greater medical interest has been awakened here in regard 
to this subject by the writings of Reade, Buzzard, Broadhurst, and Douse, 
but above all by those of Hutchinson and Hughlings Jackson. It is a 
large subject, because the functions affected are numerous ; an obscure 
subject, because the effects of the disease are often very slight and slow- 
in development, and are multifarious in kind ; and is an interesting 
subject to the alienist, because it is a disease in which the mental and 
bodily symptoms can after death be often directly connected with the 
pathological lesions present, and because in some cases the resources of 
therapeutics are most powerful and direct in curing the disease. In 
regard to the frequency of syphilitic affections, there is the most extra- 
ordinary difference of experiences among different authors. Douse makes 
the astounding statement that, of ten thousand patients under his treat- 
ment at the Central London Sick Asylum, three-fourths were the subjects 
of acquired or hereditary syphilis. That statement is enough to make 
one shudder. Its import, if a fact, to the mental and bodily future of 
London is appalling. Whatever may be the frequency of ordinary 
syphilitic affections, all authors agree that brain syphilis is rare, abso- 
lutely and relatively. Dr. Wilkes first pointed out "that when the 
primary and secondary manifestations of syphilis are least marked, the 
viscera and nervous system are affected in an inverse ratio ;" that is, we 
find that in a large number of cases of brain syphilis there have been few 
primary or secondary symptoms, and no traces of the effects of the disease 
in the viscera. My own observation confirms that of others, that the 
syphilis which ultimately attacks the brain or its membranes, has often 
lain for many years entirely latent, or apparently so, before it produced 
any symptoms at all. I think there is no doubt that a hereditary pre- 
disposition towards the neuroses determines the effects of the poison 
towards the brain. In addition, injury to the brain, previous disease, 
venereal excesses, over-study, mental anxiety or worry, and even fright, 
may all act as determining causes of brain syphilis. Lancereaux states 
that the learned professions are especially liable to it. 

Looking at the matter from a purely pathological point of view, 
"syphilis of the nervous system," though a term often used, is, strictly 
speaking, a misnomer, for Hughlings Jackson has shown that the poison 
never really attacks the nerve tissue proper at all, but only its neuroglia, 
fibrous tissue, bloodvessels, lymphatics, membranes, or bony coverings, 
involving the nerve tissue and its functions secondarily, by* pressure, so 



302 SYPHILITIC INSANITY. 

causing irritation, inflammation, and ramollissement, or by starvation from 
deficient blood-supply, and so causing degeneration and atrophy. 

Brain syphilis with mental symptoms is in this unique position, that 
in the most characteristic cases its pathology is much more definite than 
its symptoms. The pathological changes may involve any and every 
part of the brain, and in any and every degree. The symptoms, there- 
fore, mental and bodily, depend on the position and on the intensity of 
the morbid process. We may have the most acute and delirious mania 
caused by a rapidly growing destructive syphiloma in the convolutions, 
or we may have a mental enfeeblement so slowly progressing that it 
takes twenty years to run its course, caused by an obstructive arteritis 
gradually closing up the lumen of a few of the cerebral bloodvessels. 

My own experience w^ould lead me to classify syphilitic insanity into 
four forms ; and here I am conscious of the disadvantage I am under in 
having chiefly to do with the mental symptoms of brain syphilis, instead 
of having to treat of the whole subject as a pathological entity with its 
whole bodily and mental symptoms. The brain syphilis that has bodily 
symptoms only I have nothing to do with, though its pathology and 
treatment may be precisely the same as the mental cases, the only difi"er- 
ence being the locus in quo. The mere sketch I am able to give here 
of the mental symptoms will by no means exhaust the great variety of 
psychological phenomena met with in this disease. 

The first form may be called secondare/ syphilitic insanity. It occurs 
during the second stage of the disease, is coincident with the eruption, 
is curable and rare. Dr. CadelP has described a typical case. A gentle- 
man contracted an infecting chancre in January. A squamous syphilide 
appeared in April, and along with it, marked mental excitement, and an 
extreme amount of motor restlessness, this maniacal state reaching its 
height in August and September, and then almost amounting to delirium. 
" The patient took no rest in bed, was in the habit of riding and driving 
about recklessly during the night." This maniacal excitement gradually 
diminished, until in December the patient appeared to be in his normal 
mental state, this being coincident with the gradual disappearance of the 
syphilide. In the following April, an attack of mild suicidal melan- 
cholia with "paralysis of energy," came on, and lasted for over a year, 
this being coincident w^ith the falling out of the hair of the head, eye- 
brows, and beard. With the disappearance of all traces of the syphilis 
and the restoration to bodily health, the mental state also became normal 
and remained so. 

I have now a case, H. 0., a young woman of twenty, who seems to 
have contracted syphilis either just before or just after her recent mar- 
riage, and on admission to the asylum showed the characteristic eruption 
of the second stage, with sore throat and reduced condition. For eight 
days before admission she had been maniacal, and when sent here 
was almost incoherent, very uncivil, and foul in her language, being 
especially erotic and nasty in her ideas. She had, as Avell as the syphi- 
litic eruption, bronchitis, with some amount of pleurisy. She was put 
on iodide of potassium, with a little mercury and tonics, and nutrients. 

1 Journal of Mental Science, vol. xx. p. 564. 



SYPHILITIC INSANITY. 303 

She gradually improved in mind, the syphilitic eruption passed away, 
but her lung disease went on, and of that she died within six months. 

Now, such cases might be thought to be mere coincidences of an attack 
of mania with one of syphilis, were they not too common for this, and 
were the beginning and termination of both diseases not so contem- 
poraneous. I presume such moral causes of insanity as fear, remorse, 
and shame, come in and help the blood poison to start the psychosis in 
such cases sometimes. But it would be strange if the infection of the 
system and of the blood with such a virulent and vile poison did not 
sometimes derange the functions of the convolutions in persons predis- 
posed to insanity. This form of syphilitic insanity has no known 
pathology. Its treatment is that of secondary syphilis, and its prognosis 
is good. 

The second form, the delusional syphilitic insanity^ is one due, in my 
opinion, to slight brain starvation and irritation from syphilitic arteritis 
that has become arrested. It consists of an incurable monomania of 
suspicion or of unseen agency, with hallucinations of the senses, but 
without motor symptoms, following at some distance of time an attack 
of syphilis in persons strongly predisposed to insanity. It seems as if, in 
fact, the syphilitic poison had produced a subtile dynamical change in the 
brain convolutions and their trophic energy, as well as the arteritis, mani- 
festing itself in unreason, hallucinations, and an organic feeling of ill- 
being. Dr. Hugh Grainger Stewart published several graphic cases of 
this kind. One of them imagined that he underwent a kind of a nightly 
torture called by him the "cylinder finish;" another said that most 
ingenious machines were introduced into her brain to torture her ; another 
that people shot vitriol, ammonia, and "black poison" at him all night, 
to avoid which he wedged his bedroom doors, covered the key-holes with 
blankets, stuffed his ears and nostrils with cotton-wool, and his mouth 
with a pocket handkerchief, all these defensive measures against his 
imaginary bombardment taking him an hour to carry out before he went 
to bed. I have several cases of the same kind under my care just now. 
One is a woman, H. P., a prostitute, who thinks there is a network of 
wires in her brain, put there by me. Another, a gentleman, H. Q., 
strongly predisposed to insanity, his only sister being insane, who, a- 
year or two after a bad attack of syphilis, and while some of its consti- 
tutional effects still remained, developed delusions of a conspiracy against 
him, and that people affect him sexually at night.. Under the influence 
of these delusions he became dangerous. Such cases are, in my experi- 
ence, always incurable. They are liable to be complicated by alcoholic 
and phthisical causes of brain disturbance. I admit that it may fairly 
be asked about such cases — Can we not have those symptoms without 
the occurrence of syphillis at all from mere heredity taking this develop 
nient? I think we can. Or is there such proof in any of those patients 
that have been sypliilitic that this poison or its trophic effects were really 
tlu^ causes of the mental derangement ? In many of them certainly the 
time between the supposed cause and its eftects was long, and altogether 
the scientific proof of their connection is Aveak. Still tlie coincidence of 
this type of case with previous severe attacks of syphilis is certainly 
very marked in a large number of cases. There is a general resem- 



304 SYPHILITIC INSANITY. 

blance between the mental symptoms of such cases and those of the case 
of "vascular syphilitic insanity" (case of H. S., p. 305), where actual 
disease was found in the arteries of the brain. 

The next two forms have a very definite pathology. One, the third 
on the list, may be called the vascular syioliilitic iiimnity^ and the fourth 
the '' syphilomatous insanity.'''^ The one depends on the tendency of 
the poison to affect the bloodvessels of the brain and cause slow arteritis, 
with diminished blood-carrying capacity and consequent slow starvation 
of the cerebral tissue. The other depends on the tendency of the poison 
to affect the connective tissue, neuroglia, membranes, and bones, and 
cause pressure, irritation direct and reflex, and inflammation in the con- 
volutions. Any other causes of arteritis, or tumor, or pressure, or irrita- 
tion than syphilis, would probably produce somewhat the same mental 
symptoms, and, as a matter of fact, some of those mental symptoms 
follow non-specific arteritis and tumors, and also traumatic lesions of the 
brain. Yet the syphilitic cases, though not absolutely pathognomonic, 
are nearly so in most instances. 

Of the vascular syphilitic insanity I give the following cases out of 
many I have met with, because they are very typical : H. K., when he 
was a student, was infected with syphilis, which ran a bad course, and 
many of its somatic effects never left him, e. g,^ copper-colored spots and 
baldness, and, as we shall see, his liver was the seat of an old gumma- 
tous deposit. He entered the church, married, and procreated several 
unhealthy children. In twelve years after his attack of syphilis he 
became changed mentally and morally, showing a morbid irritability, 
threatening violence to his wife and children, disregarding the decencies 
of life, and the proprieties of his social station and profession, going 
about his parish telling improper stories, and not conducting himself 
rightly in regard to some of the female members of his congregation. 
On admission to the asylum, his mental symptoms were those of simple 
coherent "reasoning mania." He had stricture, copper-colored blotches 
on his skin, and irregular baldness. After being in the asylum a month 
he affirmed he had several "fits," but there was no proof then of con- 
vulsions. He was untruthful, malicious, showed no natural feeling, and 
no self-respect. He was a year in this asylum, and was then transferred 
to another. His mental power steadily deteriorated; he became subject 
to regularly recurring convulsive seizures ; after some years he had, along 
with general weakness, a partial paralysis of the left side, with incon- 
tinence of urine, thickness but not tremulousness of speech. Mentally 
he passed from irritability into enfeeblement and loss of memory; from 
that into stupor, in which state he died thirteen years after he first 
showed mental symptoms, and twentj^-five years after he had contracted 
the attack of syphilis which had been at the root of all his ills. 

On jjost-mortem examination the calvarium was found condensed, and 
the right side of the frontal bone thicker than the left. The dura mater 
was much thickened, congested, and adherent to the bone and to the pia 
mater, and this last to the brain convolutions, so that the dura mater 
could not be removed without lacerating the convolutions. This was par- 

1 Mr. Hayes Xewington, .Journal of Mental Science, vol. xii. p. 555. 



SYPHILITIC INSANITY. 305 

ticularly the case over the parietal and frontal lobes. On section, a great 
part of the centre of the anterior lobe of the right hemisphere, and many 
of its convolutions, were found to be atrophied, the place of the neurine, 
white and gray, being taken by a flocculent, gelatinous, fibrous material. 
The outer layer of the gray matter of those convolutions was found to 
be normal looking. On the left side of the brain the white matter was 
generally lacking in consistence — pale in some places and congested in 
others. The lining membranes of all the ventricles were very granular. 
The basal ganglia on the right side were softened and congested. 

An examination of the arteries of the brain showed a hypertrophy of 
all the coats, causing extraordinary obliterations of the lumen in places, 
irregular contractions, and nodulated thickenings. Every form of irreg- 
ular local arteritis was found, all the vessels being more or less aifected, 
but especially the branches of the middle and anterior cerebral passing 
to the atrophied part of the right hemisphere. 

The spinal cord was found to have undergone general atrophy with 
anaemic and softened portions in the dorsal region, and intensely con- 
gested portions in the lumbar region. The dura mater, pia mater, arach- 
noid, and cord were all matted together in some places. The liver was 
found to be puckered with cicatrices, and to have a small gummatous 
tumor the size of a bean in one portion of it. 

It was evident that here there had been a syphilitic inflammation of 
the membranes; but the great bulk of the mental and bodily symptoms 
could be traced to the effects of the arteritis causing first irritation in the 
brain convolutions and then a slow process of blood starvation. The real 
character of the case was never diagnosed during life. 

In the following case the arteritis seems to have ceased to get worse at 
a very early period of the disease, and its effects mental and bodily were 
therefore almost stationary for thirty-five years: H. S.,^ set. 30 on 
admission. Patient had a severe attack of syphilis at seventeen, for 
which he was treated with mercury. After this he was always irritable, 
and sometimes violent. On one occasion he attacked his mother, and 
smashed the door of a neighbor's house with a poker, and, when taken 
to the police ofiice, that night had a partial hemiplegic attack. He was 
for ten years in a private asylum at Musselburgh, and then was taken to 
Morningside. On admission, he had delusions of suspicion, impulsive- 
ness, violence, and also hallucinations of hearing, fancying he heard 
voices calling him "low," "mean," and seeing figures that he imagined 
jumped down his throat. He was taciturn and melancholic, too. 

In three years his delusions were worse. He seemed to have had a 
slight difficulty of speech, and he imagined a woman hud located herself 
in his mouth and was the cause of this, as well as of a bitter taste in his 
mouth. His gait was a little unsteady, straddling, and ataxic, and he 
dragged one leg a little. His bodily condition was never strong, and he 
looked weary and pale, and he always suffered more or less from dys- 
pepsia. His delusions, impulsiveness, and excessive irritability of temper 
continued for the twenty-six years he lived in the asylum ; and superadded 

^ This case was more fully reported by the late Dr. J. J. Brown, then assistant physi- 
cian, Koyal Edinburgh Asylum, in the'^ Journal of Mental Science, July, 1875. 

20 



306 SYPHILITIC INSANITY. 

to these there was considerable general enfeeblement of mind. His legs 
got weaker before death in 1875. He died of diarrhoea. The brain 
membranes were thickened, a thin layer of blood-clot was found under 
the pia mater, and the convolutions were much atrophied. There was a 
small cyst in the pons, evidently from old apoplexy. The microscopic 
appearances were the most striking (see Plate VIII., Figs. 1 and 2). 
The arteries in the pons were thickened, the muscular coats being hyper- 
trophied to an enormous extent, the outer coat being also much thickened, 
and in and around this coat was a molecular deposit (Plate VIIL, Fig. 1) 
containing also granular masses, this deposit in many instances filling up 
the perivascular space. At some parts the vessels were patent, at others 
completely occluded, and the lumen absent, the artery presenting the 
appearance of concentric rings in the centre of a granular deposit. The 
gray matter of the convolutions was found to be degenerated, the cells 
being atrophied, and their spaces in many instances being occupied by a 
few granules (see Plate VIII., Fig. 2). The spinal cord was also affected 
in the same way in its arteries, and in its gray and white substance. 
There were many microscopic apoplexies in the white substance of the 
cord. 

iSTo better demonstration of chronic vascular disease of syphilitic origin, 
and its effects of brain starvation, degeneration, and atrophy, with the 
resulting mental suspicions, hallucinations of hearing, and lack of self- 
control, could have been afforded than this case. 

I have seen some of the most extraordinary pathological effects in the 
brain fi'om slow syphilitic arteritis. I have several specimens of brains 
in which the whole of the white substance in the inside of the anterior 
and middle lobes, lying between the outside convolutions and the central 
ganglia, had gradually and entirely disappeared, leaving a vacant space 
filled with fluid and a few fibrous flocculi. The gray substance of the 
convolutions, looked at from the inside in an antero-posterior section of a 
hemisphere, presents the most extraordinarily defined appearance, just as 
much so as when looked at from the outside (see Plate V.). The convo- 
lutions looked as if the white substance had been carefully pared off them, 
leaving the gray matter intact. The effect was exactly what would have 
resulted had that portion of brain been steeped in a fluid which had the power 
of dissolving away the white substance and leaving the gray entire. The 
cause of this is no doubt the histological facts that (1) the gray substance 
of the convolutions has five times the amount of capillary blood-supply 
of the white; and (2) the source and mode of supply is different, the 
gray substance getting it from the already divided and anastomosing net- 
work forming the pia mater, and the white substance getting its supply 
from single vessels, which in dividing form only an infi-equent anasto- 
mosis, and a network with large, long meshes. The white substance, in 
fact, slowly dies, and disappears through an arteritis which only causes 
partial atrophy, anaemia, and lessened mental function in the gray con- 
volutions. Looking at such a brain, many questions suggest themselves. 
How do the convolutions act whose white fibres of communication inwards 
and their interconvolutional fibres have quite disappeared? Is there a 
general power of conduction in the convolutions from one through the 
next, and so on till it reaches one whose ingoing fibres are intact ? Can 



PLATE V 




PLATE VIII. 




Jami's Robe rtsuj], Del' 



G \\ fitf rsinu cic 5ons Litho Edmo j .-gh 



SYPHILITIC INSANITY. 307 

the convolutions still act in some degree even deprived of their projection 
and association system of white fibres? 

Most of the vascular cases have the general course of H. R. Mentally 
a change of character, morbid suspicions, loss of self-control and of the 
moral feelings, a disregard of the decencies of life, then an intense irri- 
tability, often with violence and a loss of memory, then an enfeeblement 
of the mental power, ending in complete dementia. Bodily, an unhealthy 
and cachectic general state, a lack of trophic power, with no cephalalgia 
necessarily, then a general failure of muscular power and a tendency to 
partial paralysis, then occasional epileptiform fits, sometimes unilateral, 
but never more localized than a motor paralysis that advances and recedes 
in a puzzling way, then loss of power over the sphincters, loss of trophic 
power, and death, if that has not occurred before through an attack of 
convulsions. The duration is very different in different cases, but in my 
experience it is never less than five years, and may be twenty-five. If 
one was fortunate enough to be able to diagnose a case in the earliest 
stages, no doubt the iodide of potassium, with nerve tonics, nutrients, 
and brain rest, should be prescribed, and I think I had a case where these 
measures saved the patient from going further than mild and manageable 
childishness, without tendency to convulsion. But if the lumen of an 
artery has been lessened by slow syphilitic arteritis, we have no reason 
to think it can, by any therapeutic means, be made more patent ; and if 
some of the brain tissue has already been starved into atrophy, most 
certainly it would be a groundless hopefulness to think of its possible 
restoration. 

Looked at purely from the pathological point of view, the arteritis may 
affect vessels of any and every size down to capillaries, may thicken the 
fibrous or the muscular parts of the arterial wall, or any of the coats. 
It is usually irregular and local, and often nodular. I do not know any 
more instructive demonstration of the visible effects of a lack of blood 
supply on brain cells and fibres than may be found in sections from dif- 
ferent parts of a brain affected by syphilitic arteritis (Plate VIII., Fig. 2). 

The fourth or sypMlomatous form is so exceedingly various in its 
symptoms, mental and bodily, that I really do not know where to begin. 
It may consist of a syphilitic meningitis attended with a temporary 
stupor and delirium, which is most curable by the iodide of potassium. 
Or it may consist of a quick-growing syphiloma within a convolution, that 
causes in a few weeks extensive softening, wild maniacal excitement, 
general convulsions, and paralysis, and speedy death ; the whole process 
being from the beginning absolutely beyond the reach of cure, or even of 
alleviation. Or it may consist of local gummata, causing pressure, local 
convulsions, mental irritability, and very slowly progressive dementia. 
Or it may consist of great cakes of syphilitic inflammation and gummatous 
or semipurulent deposit over one or both hemispheres, causing gradual 
dementia, and at last coma. Or it may be a membranous or bony tertiary 
lesion that has been quite arrested in its growth, but has sot up what is 
practically epilepsy and ordinary epileptic insanity. I shall just give an 
idea of the disease by referring to a few cases. I shall first illustrate the 
more acute forms by the following case of syphilitic tumor of rapid growth 
within the substance of the brain : 



308 SYPHILITIC INSANITY. 

H. T., aet. 26, a prostitute, whose history was not known except that 
she had been deliriously maniacal, cephalalgic, and 'had taken convulsive 
attacks. On admission to the asylum she was vacuous and taciturn, and 
almost in a condition of stupor. Her pupils were unequal, but there was 
no motor paralysis visible. She wakened up partly, and spoke in a slow, 
hesitating way. After being in the asylum for a month, and taking 
many convulsive attacks during that time, she died suddenly one day 
after such an attack. A small gummatous tumor was found in the centre 
of the anterior lobe of the right side, involving one of the frontal con- 
volutions, and this was surrounded by a great ring of white softening and 
brain anaemia, and that again by an outer ring of congestion. I had 
lately another case very similar to this, H. U., aet. 41, with no ascertain- 
able history of syphilis, but who had had several miscarriages. Her 
uncle had been a patient in the asylum. For a year she had suffered 
from intense cephalalgia, mostly on the right side, passing to the forehead 
and affecting her sight. For six months she had had fainting turns, and 
for three weeks convulsive attacks. On admission she was mentally con- 
fused, complained of voices round her bed, and talked wildly and inco- 
herently about things that had no connection with the questions asked 
her. She began to take convulsions a fortnight after admission, and died 
of these in three weeks. I had during life diagnosed brain tumor, prob- 
ably syphilitic. After death we found under the dura mater several 
hemorrhagic patches. The convolutions presented a flattened "glazed" 
appearance. Section of the brain showed great pallor of the white sub- 
stance of the left hemisphere. In the lower and middle part of the left 
internal capsule there were two small gummatous tumors, one the size of 
a big bean, the other the size of a filbert. They were surrounded by an 
area of loose, disorganized, softened brain substance, involving the an- 
terior third of the corpus striatum^ spreading through the temporo- 
sphenoidal lobe, the whole of which was pulpy. The softening extended 
also along the posterior horn of the lateral ventricle. In the right 
hemisphere there was also an abnormal pallor, but there was no softening 
except in the posterior lateral ventricle, which presented much the same 
appearance in a less degree as on the left side. There was no tumor or 
deposit on the right side. 

This exemplified what is very commonly found in the brain, viz., a 
symmetrical lesion on both sides of the brain in exactly the same place. 
My experience is that vascular and atrophic lesions of the brain, such as 
apoplexies, large or capillary softenings, and thrombosis, are exceedingly 
apt to occur in both hemispheres in the same places and almost at the 
same time. This vascular and tropho-organic sympathy of the two 
hemispheres, extending to diseased conditions, is a most important fact 
not noticed in pathological works, but physiologically and pathologically 
it must be kept in mind in brain study. 

In both the above cases the cerebral bloodvessels seemed normal. A 
small, local, quick-growing syphiloma in the brain substance had caused 
surrounding destruction by pressure and irritation, setting up an inflam- 
matory process, and causing tissue death. The symptoms had been 
cephalalgia, convulsions, mania, confusion, loss of attention and memory, 



SYPHILITIC INSANITY. 309 

and sudden death within a short time. I have since met with two cases 
of the same kind of much slower course and without convulsions. 

The next example I shall take of brain syphilis is one that most 
physicians would not be inclined to regard as one of "insanity" at all, 
though, as a matter of fact, the patient was incapacitated for work, con- 
fused and stupid in mind, and at times delirious. But, being a clear 
case of brain syphilis of a common type, with mental symptoms cured at 
home by appropriate treatment, it is more important to the practising 
physician than cases with more decided mental symptoms. 

H. V.J aet. 33. Patient's mother had been insane for a year, '' after 
a fall on the head." He had had syphilis six or seven years ago, with 
few secondary symptoms. He had not been feeling well for six or seven 
weeks, suffering from very severe headaches. Three weeks ago he took 
suddenly a very severe attack of general convulsions with unconsciousness. 
Before that he had on several occasions a rather pleasant momentary 
feeling of " being in a trance," and this sensation preceded the fit. 
When taken home after the fit, he was confused and had severe cepha- 
lalgia, and had slight left hemi-paresis. He went to the late Dr. Begbie, 
who prescribed iodide of potassium in five-grain doses. Since then he 
had travelled about a little, and tried to do business, but could not do so 
properly on account of loss of memory, lack of power of attention, general 
confusion of mind, and severe cepha^lalgia. When I first saw him, he was 
considerably paralyzed in the left side ; he had double vision, and a loud 
noise in the right ear ; he was confused, mentally depressed, his memory 
very poor ; he was irritable, wayward, tending to be violent, and difficult 
to manage. If he had been a poor man, he would probably have been 
sent to an asylum at once. He suffered the most fearful cephalalgia, 
especially at night, and the slightest tap, especially over the right side of 
his brow, greatly increased his sufferings. The skin of the right side of 
his head and face was hypersesthetic, and his right conjunctiva injected. 
He could not read or write. Pulse 80, temperature 98.4°. Appetite 
gone, tongue much furred. I put him at once on ten-grain doses of the 
iodide of potassium, with fifteen grains of the bromide, and one-twelfth of 
a grain of the bichloride of mercury thrice a day, with milk and potass 
water alone for diet. For about a week he got no better, suffering the 
most fearful agony in his head at night, becoming delirious, and wanting 
to go out at the window. I tried chloral in twenty-five-grain doses re- 
peated every two hours, as well as the bromides and tincture of cannabis 
mdica, in large and repeated doses, to dull the night pain and procure 
sleep, but with only very temporary relief. In the mornings, after those 
medicines, he was always more confused and irritable, and had no ap- 
petite. By far the best thing I found for easing the night cephalalgia 
and procuring sleep was to make him lay his head on a rubber bag'of 
almost unbearably hot water. After a week the cephalalgia aba'ted, 
he got a little more sleep, he became less irritable and confused and 
less frecpicntly delirious, and he looked better, but the paralysis did not 
improve for a fortnight, and then I raised the dose of the iodide to fifteen 
grams three times a day. In three weeks the double vision ceased, and 
he began to walk and grasp better. The cephalalgia became moroly 
paroxysmal, and took the form of neuralgia of the supra-orbital branches 



310 SYPHILITIC INSANITY. 

of the fifth nerve. He became less sensitive to tapping his head, his 
tongue got clean, and his appetite so ravenous that I had much dijBBculty 
in keeping him from eating flesh diet. In a month he was still further 
improved, could walk, read, and dictate a little, and was able to be out 
in the open air, though any exertion, mental or physical, produced a 
sense of intense exhaustion. The noise he had in his right ear disap- 
peared about that time, and also a feeling of cold on that side of the face. 
In five weeks he was almost convalescent, and mentally normal, though 
he had on two occasions the "trance" feeling that preceded the convul- 
sions. In two months he had what was evidentl}^ a syphilitic inflamma- 
tion of the periosteum over the mastoid process of the right temporal 
bone. He omitted the iodide for a week at my advice, but at once he 
began to feel worse in all respects mentally and bodily. I then increased 
the dose to twenty grains three times a day. This he took steadily for 
two years without showing a trace of iodism ; on the contrary, getting 
fat and strong, and mentally vigorous. A dimness of vision in the left 
eye and a tendency to pains and slight weakness in his left side on damp 
days, were the last of the symptoms to disappear. After two years I 
finally stopped the iodide, after having several times tried to do so before 
with bad results, and he keeps well and fit for business, with just a trace 
of head symptoms at times. 

This was no doubt a case of syphilitic inflammation and thickening of 
the membranes of the brain over the right hemisphere, affecting the cor- 
tex of the organ and its functions mental and bodily by pressure and 
inflammatory irritation. There was no doubt a gummatous deposit there. 
The beneflcial eff"ects of large doses of the iodide, and the tolerance of 
those doses for so long after the symptoms had apparently disappeared, 
is the common experience in these cases. The mental symptoms were 
characteristic in all respects. I have had other cases of this kind, not 
put under treatment so soon, which have gone on for years partially 
paralyzed, subject to convulsions, and at last dying. In one such case 
(H. U.) I found a cake of gummatous semipurulent material covering the 
whole anterior portion of the vertex, causing pressure on the convolutions, 
and destructive softening of their outer layers. The calvarium was soft, 
eroded, and spongy. In another case still in the asylum (H. X.), 
recorded by my then assistant, Mr. Hayes Newington,^ the patient had 
syphilis when young — having a necrosis of a portion of the left side of 
the OS frontis, which healed up however. During her married life she 
had four still-born children, and then three living ones. At the climac- 
teric period she began to take epileptic attacks, which have continued 
periodically ever since, the convulsions always beginning at the right side. 
She was at first periodically maniacal, with hallucinations of the senses 
and severe pain in the seat of the old necrosis, and she has gradually 
become demented, with occasional exacerbations of maniacal restlessness 
and talkativeness — in fact, she has become an epileptic dement. In such 
cases, as Mr. Newington says, " there is little doubt that syphilization 
stands as the first link of the chain of factors, and, of course, the 

1 See Journal of Mental Science, vol. xix. p. 555. 



SYPHILITIC INSANITY. 311 

insanity (now dementia) may be regarded as the last" — that last link not 
being forged till thirty years after the first. 

In the following case a syphilitic tumor of slow growth pressed on the 
brain, eroded the bone, and caused the usual mental and bodily symptoms 
of brain tumor : H. Y.,^ set. 47 ; history unknown. He had been a 
wanderer over the earth. He had the marks of syphilitic disease. He 
was depressed, confused, irritable, had no memory, and his general 
mental power was enfeebled. He was restless, with an unsteady, 
shuffling gait, and had vertiginous and epileptiform attacks. His left 
arm was subject to involuntary and uncontrollable twitchings, with pain if 
the arm was held steady ; slight left hemiplegia in leg, with partial left 
facial paralysis. He had slight ansesthesia of left cheek and arm, shown 
by his not being able to localize a pin prick there. When pricked in 
left arm he felt it in left thigh ; this parsesthesia, however, disappeared in 
three or four days. There was at the summit of the parietal eminence 
on the left side of the head a tender spot, which, when tapped, caused 
the left leg to be thrown into a state of convulsion and twitching, the 
patient still remaining conscious. He had copper-colored patches over 
his body, and a small tumor in right groin. He was put on large doses 
(twenty grains three times a day) of iodide of potassium, with small 
doses of the bichloride of mercury, but with no benefit. He died, a 
month after admission, in an epileptiform attack. 

On post-mortem examination it was found that there was an erosion 
penetrating the skull-cap, making a hole through it of an oval shape, 
nine-sixteenths inch long by five-sixteenths inch broad, where the ten- 
derness had existed during life. The dura mater was adherent round 
this point, and enormously thickened — being a quarter of an inch thick 
at some parts. I often come across such thickenings of the dura mater 
in the bodies of the insane, and they cannot be considered specific. On 
the removal of the dura mater a hard gummatous tumor was seen in two 
nodules, together about the size of a pigeon's egg. The brain convolu- 
tions round this had been pressed so as to cause some atrophy and 
softening. I have never seen a syphilitic tumor of the brain where the 
cerebral substance round it and in contact with it was sound, while I have 
seen all sorts of other tumors, even of large size, embedded in normal- 
looking brain substance. The tumor by its pressure outwards had 
caused the erosion in the skull-cap. It involved chiefly the supra-mar- 
ginal convolution, and also to some extent the ascending parietal. The 
angular gyrus was also involved. 

Out of thirty one hundred and forty-five cases of insanity of all classes 
of society admitted into the Royal Edinburgh Asylum during the past 
nine years, sixteen have been cases of syphilitic insanity, or about one- 
half per cent. Few of these recovered, or are likely to recover, the 
majority of the patients being far advanced in their disease before 
admission, with serious involvement of the structure of the brain. 

1 Case reported in Journal of Mental Science, July, 1879, p. 216. 



312 ALCOHOLIC INSANITY. 



ALCOHOLIC INSANITY. 

I do not speak here of the use of alcohol as a general cause of all 
kinds of insanity. It is unfortunately the most common of all the causes 
of the disease, in some cases producing it de novo, in others bringing into 
activity hereditary and acquired brain weaknesses. From fifteen to 
twenty per cent, of the cases of mental disease may, taking the country 
through, be put down to alcohol as a cause, wholly or in part. As a 
cause of insanity it is not followed by constant results. Conditions of 
mental depression, of exaltation, of enfeeblement, of stupor, of morbid 
impulsiveness, may all be caused by it. General paralysis, paralytic 
insanity, epileptic insanity, adolescent insanity, and climacteric and senile 
insanities may be due to alcohol as exciting causes of the attacks. When 
so caused, we do not call these alcoholic insanity. I have no time 
to speak here of those most interesting degenerations of individuals and of 
races that follow the excessive use of alcohol. Two great French 
alienists, MoreP and Moreau de Tours,^ have told us nearly all we 
know of that subject. They looked at the insanity as one of the effects 
of evil conditions of life, of bad and insufficient foods, of the use of all 
sorts of neurotics in changing for the worse the type of human being in 
the first and in the succeeding generations. There are few of the unfa- 
vorable conditions of life that by themselves cause more human degenera- 
tion than the excessive use of alcohol. Many of the American Indian 
tribes, fine races to begin with, have been simply killed off by it in a gen- 
eration or two, degenerating in body and mind all the time. You are 
aware of the pathological tissue-degenerations that are caused or promoted 
by it, the atheromatous, the fatty, the cirrhotic changes that take place 
in the vascular, the renal, the hepatic, the glandular, the fibrous, and the 
nervous tissues. Those are the individual tissue and single organ damages. 
The whole organism suffers somatic and mental lowering, alteration 
of function and of energizing. These degenerations are transmitted from 
generation to generation in the same or other forms by hereditary laws, if 
not corrected by new and improved conditions of life. In some individuals 
they are mere potentialities and tendencies, in others they have assumed 
definite forms, and become insanity, idiocy, stuntedness of growth, ugliness, 
deformity, deaf-mutism, sterility, incapacity for high kinds of education, 
immorality, and lack of general control. Those are large general ques- 
tions, of the highest interest socially and physiologically. They often 
become very practical questions to medical men. Alcoholic degenerations 
influence the type of all ordinary diseases, and they interfere much with 
the treatment adopted for their cure. When our profession becomes, as 
it should be, and as I have no doubt it will in time become, the guardian 
— by prophylaxis — of the physical and mental well-being of the people, 
and the great source of authority for the regulation of the conditions of 
life, such questions will come far more to the front than they do at 
present, and they must then form an important part of medical study. 

^ Traite des Degenerescences de I'Espece Humaine. 
' La Psychologie Morbide. 



ALCOHOLIC INSANITY. 313 

Meantime I have merely to describe and illustrate those forms of mental 
disease, in which alcohol has not only been the cause, but has so influ- 
enced the symptoms that they are in some way special or peculiar, so 
that the mental and bodily results are, as it were, specific, and so may be 
called alcoholic insanity. No agent that I am aware of has such dif- 
ferent results on different brains as alcohol. For that reason alcoholic 
insanity is not in all cases of the same kind. 

Acute Alcoholism. — The most typical alcoholic insanity is Delirium 
Tremens^ or acute alcoholism. That this is described in ordinary text- 
books on Practice of Physic, and is treated usually at home or in general 
hospitals, and is of short duration, does not make it less a true insanity. 
From a symptomatological point of view it is a typical excited or motor 
melancholia, characterized especially by hallucinations of sight, fleeting 
delusions of all kinds, but especially delusions of suspicion, suicidal 
feelings, partial or complete incoherence, failure of memory, great con- 
fusion, tendency to mistake identities ; in some cases by unconsciousness, 
and by loss of power of attention. It is the bodily symptoms that give 
it its most characteristic features. The motor restlessness and the motor 
tremulousness combined are excessive and constant. In addition the 
temperature is usually above 100°, there are paralysis of the appetite for 
food, often sickness, generally lack of digestive power and assimilation, a 
rapid loss of body-weight, and absolute sleeplessness. In typical cases, 
and in the first or second attack, it runs a somewhat definite course, and 
has a short duration measured by days or weeks. Such cases are now 
often certified as insane and sent to asylums for treatment, and but for 
the idea connected with an asylum they are best treated there. We have 
the means of treating them more satisfactorily there, according to the 
present ideas of treatment, than in a hospital. We have trained at- 
tendants, suitable rooms, grounds for exercise, and no necessity for the 
use of narcotics used merely to keep the patient quiet and manageable. 
The patients often recover sooner with us than in hospitals, chiefly 
because we can keep them after the first day or two in the open air. I 
do not recommend patients suffering from acute alcoholic insanity to be 
sent to asylums if they have money enough to have good skilled attend- 
ance, and can be sent to a lodging in the country or outskirts of a town 
after the first few days, simply because the notion of having been in a 
lunatic asylum is repugnant to most men's feelings, and it may be more 
injurious to a patient afterw^ards than if he had been treated in a hospital 
or at home. It would be easy enough for all large general hospitals to 
have some rooms and an exercise ground for the treatment of such cases. 
The chief difficulty is the expense of keeping a permanent staff of two 
good trained attendants for work that would be only occasional. 

Here is a good case of acute alcoholism sent to an asylum. J. A., 
set. 34. Has had several attacks of the same kind before. Drinks in 
bouts, not steadily. Is of an excitable, sensitive disposition naturally. 
Has been ill for about a week, during which he has not slept. Is chat- 
tering incoherent nonsense, addressing imaginary persons in short, snatchy, 
semi-incoherent sentences. His attention cannot be roused to attend to 
the questions put to him ; evidently has hallucinations of hearing and of 
sight. He looks up at the ceiling and round the walls as if following 



314 ALCOHOLIC INSANITY. 

some object with his eyes, and turns and says, " Yes," "What is it ?" etc., 
as if in answer to questions or remarks. He is very restless and tremu- 
lous, so that he cannot hold a cup to his lips and drink out of it without 
spilling. The temperature is 101°, pulse weak and quick, skin perspiring, 
eyes sunk, expression of face haggard and almost vacant, pupils dilated 
but sensitive, tongue tremulous and coated. His articulation was markedly 
tremulous, like that of a general paralytic, only thicker. The reflexes 
were dull, and the spinal reflex action almost gone — in this last respect 
differing from nineteen out of twenty general paralytics. His general 
strength was very low. He w^as put to bed and fed with milk, and 
eff"ervescing potass water, alternated with beef-tea. He was made to 
take those things by attendants contrary to his inclination. He was 
sent out to walk assisted by an attendant for an hour the first day, and 
that night he was fed every hour irrespective of his inclination. He 
scarcely slept. Next day he was fed regularly, and was out in the open 
air most of the day. His pulse got stronger and he slept two hours that 
night, and his temperature fell to 100°. The same treatment was adopted 
day by day, and no medicine was given him but quinine and nitro-muriatic 
acid, which were prescribed after the first two days. In four days he was 
coherent and less tremulous, and could sit still. In a week he was ra- 
tional, and in ten days he was well, all but the sense of exhaustion. 

Some cases do not turn out so well. There are five chief risks from 
the alienist's point of view that I have met with. The first is that of the 
brain passing from a melancholic mental condition into that of stupor and 
coma. This takes place in very bad cases that have soaked and lived on 
alcohol for years. I had a great, stout, flabby-looking woman, J. B., 
once, w^iose case took this course, and she died in ten days. She had 
had alcoholic convulsions before admission, and had been dosed with 
opium. We found intense brain congestion, thickening of the mem- 
branes, and the outer layer of the gray matter of the convolutions dis- 
eased microscopically, being full of proliferated nuclei. The second risk 
is the persistence of the hallucinations of hearing after most of the other 
symptoms have gone. This is apt to occur where there have been many 
previous attacks, and a neurotic heredity. The treatment is exercise in 
the open air and mental distraction from morbid fancies. Most of them 
will so recover in a month or two. The third risk is the persistence or 
aggravation of the insane suspicions of poisoning, of conspiracy, or of 
being worked on by electricity and unseen agency. In fact, the case 
becomes one of delusional insanity. This is very common, especially the 
delusion of poisoning. This arises out of a misinterpreted sensation. 
There is chronic gastritis or indigestion from alcoholic irritation of the 
mucous membrane of the stomach, and the patient attributes his bad 
sensations to poison. I had one man, J. C, who retained for years the 
delusion that I had put rats inside him, but he recovered through proper 
regimen and abstinence. Such cases, as well as those with the persistent 
hallucinations of hearing, are frequently very suicidal, and need care and 
watching on that account. The subject of the danger of suicide in all 
kinds of alcoholic insanity has not been at all sufficiently dwelt on. I 
believe that more suicides, and combined suicides and homicides, result 
in the country from alcoholism in its early stages than from any other 



ALCOHOLIC INSANITY. 315 

cause whatsoever. The fourth risk is that the man's brain and the man 
himself gets out of the attack with the finer points of his moral character 
and feeling rubbed off. He is mentally different from his former self, 
though not insane. He is more untruthful and unfeeling, coarser in the 
grain, more lazy, and less honorable. His brain has undergone an or- 
ganic change to some extent. Instead of fine membranes, they are milky 
and thickened ; instead of pure brain substance, it is mixed with pro- 
liferated neuroglia and adventitious tissue. The fifth risk is run in 
patients who have a heredity to insanity, and who have frequently had 
alcoholic insanity. Instead of the attack resolving itself in the natural 
way, it runs into an attack of ordinary melancholia or mania, which ends 
in dementia. In fact, there are few cases that pass into dementia at once 
out of the attack of acute alcoholic insanity, or even without this — a de- 
mentia characterized chiefly by a loss of memory, a listlessness and in- 
action, and yet a coherence and apparent power of reasoning not seen to 
be unreal till you test them. Such cases have been soakers for years. 
I have one such gentleman now, J. D., who once had a powerful intel- 
lectual brain, well stored with literature and professional knowledge. 
He drank steadily for over twenty years, and then had an attack of alco- 
holism, with symptoms of kidney degeneration and hepatic cirrhosis. He 
now talks very rationally, dilates on the cruelty of his being in an asylum, 
and on his being ruined by being kept from his business. He has no de- 
lusions, and, if you give him the cue, will repeat half a play of Shakes- 
peare's, and tell you all that occurred to him twenty years ago ; but 
when you ask him the day of the week, or what he had for breakfast, he 
cannot tell you in the least. When I say to him (and this has been my 
stock answer to his complaints * of improper detention for ten years), 

"Well, Mr. , write to the commissioners and state your case," 

he will reply, " I'll do so at once ; there never was such an outrage com- 
mitted on a man before." Yet, in ten years, he has never written to the 
commissioners, though a lawyer. He wanders lazily about our grounds, 
of which he has the parole, day by day, and is always happy in a negative 
way, except during the few minutes he dilates to me on the frightful 
cruelty of his being in an asylum. I had another such case, who could 
not, for a long time, remember his own name. His brain had to be re- 
educated to this simple act of memory. Such patients are usually fat 
and torpid in movement. They have lost the fine lines and movements 
of facial expression. Their affective nature is dulled or twisted. They 
often have lost the craving for stimulants in this state. 

Chronic Alcoholism. — The next form of alcoholic insanity is that 
condition commonly known as chronic alcoholism. This is also always 
accompanied by motor signs, many cases indeed not being technically 
"insane." It is often ushered in by alcoholic convulsions. A long- 
continued, steady soaking in alcohol is, I believe, much more damaging 
to the brain in its mental, motor, and trophic functions than bouts of 
heavy drinking with intermissions of sobriety. In chronic alcoholism, 
looked at, as I am doing, chiefly from the mental point of view, all the 
symptoms are less acute and last longer than those of acute alcoholic 
insanity. The suspicions and fears of the latter become a chronic symp- 
tom, the delusions are less numerous and more apt to become fixed. 



316 ALCOHOLIC INSANITY, 

The hallucinations of sight are absent, but we are far more apt to have 
hallucinations of hearing. There is loss of inhibitory power, and there- 
fore tendencies to impulsive acts. There is sleeplessness, but it is not so 
absolute. There is motor incoordination, but not so much restlessness. 
The speech is thick and often tremulous ; the tongue very quivering and 
incoordinated in its movements. The functions of the cord are affected, 
causing a slightly ataxic walk and an abolition of the spinal reflexes, and 
sometimes of the tendon reflex. The temperature is usually about 99°. 
The appetite is never keen, and the taste often perverted, so that the 
patient complains of food not being what it professes to be. 

Here is a typical case, J. E., set. 41, an innkeeper, whose brother 
committed suicide, and who has drank hard for many years — whiskey being 
his liquor. His present attack began with sleeplessness, and restlessness, 
insane suspicions, and hallucinations of hearing. He thought his wife 
poisoned his food and kept men in the house, whom he would go and 
seek at all hours of the day and night in cupboards. When sent to the 
asylum (he attempted suicide on the way) he was almost sleepless, heard 
voices all about him saying he was to be destroyed and punished, and 
the voices of his wife and family. His temperature was 98°. He was 
tremulous and shaky, and could not walk far. He could not write or 
drink out of a tumbler without spilling the contents on the floor. His 
tongue was foul, and very tremulous — he could scarcely put it out at all. 
His appetite was gone, and he affirmed that the meat we gave him was the 
flesh of his children ; he was put on the bromide of potassium and steel, 
was fed with liquid custards, which contained six pints of milk and ten 
eggs a day, in addition to some solid food. He was taken out to walk 
in the open air till he was tired three times a day, and he had a constant 
attendant by day and night to prevent him doing any harm to himself 
or others. Several times, without any warning and with no provocation, 
he has rushed at and broke windows, struck attendants, upset tables 
covered with dishes and jumped into our pond. He never could tell, 
after doing them, why he did these things. After three months' treat- 
ment he was scarcely any better. He would not read, or play games, or 
take any interest in anything, or speak to anyone except when spoken to. 
But in six months he is now much improved, and showing signs of 
recovery, which I do not expect to be perfect however. 

In such cases recovery is slow, and is very apt to be incomplete, if it 
occurs at all. A chronic degeneration of the whole of the brain plasma 
has begun. The intellectual power, the power of application, origina- 
tion, and independent energizing are weakened ; the delusions of suspi- 
cion are apt to persist ; the morals and self-respect are apt to be regained ; 
lying, stealing, and cowardice are indulged in. The affection for wife 
and children is impaired. These symptoms run on for a year or two, 
and then we have dementia supervening. But this termination is not 
invariable. First attacks are often recovered from in a way, even second 
attacks will be got over, but third and fourth attacks seldom completely. 
Instead of dementia, we have sometimes in young subjects delusional 
insanity supervening. I have one such man, with a tremulous tongue 
that he always put out to one side, who affirms he is "worked only by 
electricity," and hears voices; another who says his food is poisoned ; 



ALCOHOLIC INSANITY. 317 

another who thinks everyone near him insults him in everything done ; 
another whose ribs are broken every night by unseen enemies. All these 
delusions, you see, are misinterpreted sensations. 

The treatment of such cases consists in the use of tonics of all sorts, of 
nerve stimulants such as strychnine, and the continued current for a time, 
and especially of rigid abstinence from alcoholic stimulants and the lead- 
ing of a controlled, regular physiological life in the open air, with garden 
work if possible. 

Mania a Potu. — There is a third kind of alcoholic insanity of short 
duration, but great acuteness while it lasts, called variously mania a potu j 
or very expressively delirium ebriosiim. It occurs in the cases of 
persons, often young, with unstable brains hereditarily. It takes very 
little drink to produce it ; and in many cases looks like a prolongation 
and exaggeration of that wild drunkenness which occurs in certain people 
who are said not to "carry their liquor well." A few glasses of spirits 
make them riotous and unmanageable, and often quite delirious, uncon- 
scious, and violent. Such brains have often shown a weakness from the 
beginning, such as lack of self-control, tendencies to be easily led away 
into vice, incapacity for getting on. In some of them there exists 
a craving for stimulants, constituting the condition known as dipsomania. 
Mr. Hayes Newington, while one of the assistant physicians here, gave a 
capital account of mania a potu, with clinical illustrations. 

Dipsomania. — I have already treated of this condition in the lecture 
on conditions of defective inhibition (p. 250). 

Alcoholic Degeneration. — Lastly, I shall simply refer to the 
lowered mental condition that is apt to result from the too great indul- 
gence in alcohol, apart from technical insanity, or from an inordinate 
craving, or even from the notion of disease, bodily or mental, at all. A 
doctor of experience soon comes to observe in his patients and in his 
acquaintances a certain kind of change, mental, moral, and bodily, in 
the people who habitually "take more than is good for them." The 
expression of face and eyes is seen to be changed, the mental tone to be 
lowered, the power of application to be lessened, the self-control to 
be weakened. I am safe in saying that no man indulges for ten years 
continuously in more alcohol than is good for him, even though he w^as 
never drunk all that time, without being psychologically changed for the 
worse. And if the habit goes on after forty, the change is apt to be 
faster and more decided. We see it in our friends, and we know what 
the end of it will be, but we cannot lay hold on anything in particular. 
Their fortunes and work suffer, and yet you dare not say they are 
drunkards, for they are not. It all depends on the original inherent 
strength of the brain how long the downward course takes. Usually 
some intercurrent disease or tissue degeneration cuts off the man before 
he has a chance of getting old. I have seen such a man simply pass 
into senile dementia before he was an old man, from mild, respectable 
alcoholic excess, without any alcoholism or preliminary outburst at all. 
And I am sure I have seen strong brains in our profession, at the bar, 
and in business, break doAvn from chronic alcoholic excess without their 
owners ever having been once drunk. 



318 ALCOHOLIC INSANITY. 

I have seen many cases of insanity resulting from opium-eating, and 
one from the hypodermic use of morphia. They were very like the 
insanity of chronic alcoholism, but not so suicidal, with greater weakness 
of the heart's action, and more sleeplessness, sickness, and intolerance of 
food for the first fortnight. It is precisely the same class of persons who 
indulge in opium who indulge to excess in alcohol, and the treatment is 
the same, viz., an immediate stoppage of the drug, with much liquid 
nourishment, fresh air, and watching. I have seen two cases of insanity 
brought on by the use of chloral. They, too, were of the same generic 
type as the alcoholic cases, and demanded the same treatment. 



LECTURE XIII. 

EHEIJMATIC AND CHOEEIC INSANITIES— GOUTY INSANITY- 
PHTHISICAL INSANITY. 

The first two varieties of mental disease may be conveniently studied 
together. There can be no doubt now entertained as to the close connec- 
tion between chorea and rheumatism ; as we shall see, this connection is 
shown very vividly in rheumatic insanity, which is also an acute choreic 
insanity. Cerebro-spinal rheumatism has long been known, but in some 
of its types it does not come within the scope of a book on mental 
disease. In one variety, however, the most prominent symptoms are an 
acute delirious mania and choreic muscular movements of a violent char- 
acter. The ordinary course of an attack of rheumatic insanity is seen 
in the following case in a typical form. 

J. F., admitted January 17, 1870, aet. 24, married. First attack of 
insanity. Mother died of consumption. Father alive and well, and no 
relative insane or rheumatic. In health she was of a reserved and quiet 
but nervous disposition, steady respectable habits, and fond of her chil- 
dren. The predisposing cause df her illness seemed to have been an 
accumulation of debilitating and depressing influences, viz., ill-usage by 
her husband, poverty, cold, hard work, with insufiicient food during the 
three years since she was married, and having nursed her second child for 
fifteen months up to the period of her attack. These things caused 
a certain amount of depression of spirits. The exciting cause of her 
malady was an attack of rheumatism, not of a very acute character, 
which had lasted for two months before she became insane. She had 
pains in the back of her neck, pains and much swelling of fingers, hands, 
feet, and legs, and some feverishness ; but she was never so bad as to be 
quite confined to bed. A week before admission she suddenly ceased to 
complain of her rheumatic pains, and simultaneously with this relief she 
showed signs of mental derangement, and violent chorea of head, arms, 
and legs commenced. Her first mental symptoms were a sort of absence 
of mind and inattention to what was passing around her, taking no notice 
of questions put to her or of her children. Before being sent to the 
asylum, in addition to this mental inattention, there was great excitement. 
She tore her clothes, and tried to jump out of a second-story window into 
the street. She was quite sleepless, and the choreic movements had 
increased greatly in intensity. Her limbs were never still a moment, and 
she threw her whole body about. 

She was much excited on admission, her memor}^ almost gone, and 
with difficulty can be got to speak at all in ansAver to questions, but talks 
incoherently in monosyllables about the doctor who had attended her. 
The only question she can be got to answer is to tell her name. The 



320 RHEUMATIC INSANITY. 

existence of delusions could not be ascertained. She is a dark-complex- 
ioned woman with black hair ; rather thin, muscles flabby. Eyes dark- 
brown and sparkling feverishly, pupils contracted, equal in size. There 
are very violent choreic movements of the muscles of her face, head, 
arms, and legs. Anything she attempts to say or do voluntarily is 
accompanied by extravagant grimaces, twitchings, and contortions. 
Reflex action is diminished. Cannot articulate more than single words 
at a time, and those imperfectly. Cannot stand or w^alk, and was 
carried with great difficulty ; no tenderness of spine ; lungs normal, 
respirations twenty per minute ; heart beating quickly but regularly, no 
cardiac murmur. Pulse 108, strong. Tongue clean and moist; will not 
take food. Urine clear, acid, sp. gr. 1015 ; no albumen or deposits. 
Has not menstruated since beginning of last pregnancy. Temperature 
100.4°. Several bruises on body, especially over right buttock. She 
was carried to bed and ordered beef-tea and some brandy. She did not 
sleep, and on the following day the choreic movements of the legs ceased, 
the legs became quite paralyzed and nearly devoid of common sensibility, 
the reflex action in them being absent. Bladder paralyzed, the urine 
having to be drawn ofi" once, after which she could pass it. Muscles of 
eyelids and eyes quite under control. Not so the tongue, which she can 
scarcely put out at all, and then with a jerk to one side. Mental excite- 
ment abated, and speaks better. M. T. 99.4°, E. T. 99.6°, M. P. 80, 
E. P. 84. Takes liquid food; eight ounces of wine, strong beef-tea, and 
extra diet. She improved slowly until on the 23d January (six days 
after admission) her state was as follows : " Chorea much less severe, 
complains of pain in the knees, evidently of a nervous kind, for pressure 
slowly and carefully made does not increase it. Common sensibility 
somewhat exaggerated in legs, and some power of voluntary movement 
has returned to them, but she has little reflex movemicnt. Takes food 
well, bowels regular, no sweating, mentally confused, depressed, no 
memory, suspicious, will not believe a word said to her, wonders w^here 
she is and how she came here. M. T. 98.4°, E. T. 99°, M. P. 108, 
E. P. 100." 

24:th Jan. — To-day twitching of fingers only, except when she 
attempts any voluntary movements. More power of voluntary movement 
in left leg than right, which is almost paralyzed. Right knee slightly 
swollen. Reflex movement slight, and more active in left than right leg. 
Tongue twitches when put out, and goes towards right side. Temperature 
the same. She has hallucinations of sight and touch, saying that she 
sees an old woman coming behind her and eating her food, so that 
she cannot get any of it, and that one foot has been cut ofi*. Is depressed, 
weeps and groans. 

2Wi Jan. — Has had a relapse ; chorea worse in left arm ; complains 
of pains in arms and legs. Complains of a burning feeling all over her. 
A large slough forming in right buttock where it had been bruised. She 
complains much of the pain of this. She still cannot tell correctly the 
place touched on her legs, but when pinched she screams. Requires to 
be fed wdth a spoon, shows an aversion to food, though she is evidently 
hungry. M. T. 100°, E. T. 97°, M. P. 116, E. P. 116. She has no 
afiection of sight, and no sparks or motes before her eyes. 



RHEUMATIC INSANITY. 321 

bth Feb. — She now has so far recovered the power of her legs that she 
can stand. Chorea almost gone when she makes no voluntary move- 
ments. Mentally a mixture of stupor and depression, as before, and the 
hallucinations of sight and touch remain. M. T. 99.8°, E. T. 101°, M. 
P. 120, E. P. 120. 

She gradually improved, and her temperature fell until, on the 19th 
February, she was reported as having only very slight chorea in hands, 
but as still complaining of the pains in legs. Mentally she was still 
confused, but her memory was returning. M. T. 98.2°, E. T. 98°, M. 
P. 94, E. P. 100. 

She did not progress quite steadily, for on the 23d February her M. T. 
was 99.2°, E. T. 99°, M. P. 100, E. P. 108, and she was some days 
worse with the chorea than others ; but yet she was so far improved as to 
be, on the 15th March, out of bed nearly all day, able to walk, but the 
reflex action was much impaired in legs, and the left hand partially par- 
alyzed, and she had the sensation as if she did not feel the ground under 
her feet. Tongue now is simply unsteady when put out. Mentally less 
depressed, but still confused; very sceptical and much inclined to hide 
herself from observation ; fancies she is watched. Temperature down to 
97.8° in the morning. Is one hundred and twenty pounds in weight. 

2d April. — "Believes now what she is told, and is almost rational; 
but her right hand is swollen, though quite painless. Chorea rather 
worse, and she cannot sleep so well as usual." The sleeplessness in- 
creased, and the choreic movements began to trouble her exceedingly at 
night, and on the 4th her M. T. was 99.2°, and her pulse 104 and weak. 
As an experiment I gave her twenty grains of chloral in the morning, 
which made her slightly drowsy, and quite stopped the choreic movements 
till the evening, when they came on again, and she could not sleep. I 
then gave her forty grains of chloral. She slept soundly ; the chorea 
ceased; her temperature the next morning was 97.3°, and the pulse 84 
and stronger. Her mind had not been aifected during this little aggrava- 
tion of the chorea. The swelling of the hand remained for a day or two 
longer, and then gradually disappeared. Still the reflex action in foot 
was diminished, and she complained of intense heat of hands. Wound 
on buttock healed up slowly. 

226? April. — No chorea now except when she smiles ; she then grins 
and looks nervous in her movements. Sleeps and eats well. Industrious 
and rational. Has only gained two pounds in weight in a month. M. T. 
98.4°, E. T. 98°, M. P. 96, E. P. 84. 

Her recollection of the coming on of the disease is imperfect, and she 
has no remembrance of the choreic movements beginning. Her mind 
must have been afiected quite simultaneously with their appearance or 
before them. She does not even recollect the rheumatic pains going 
away. She says that she had no conscious feeling of weakness or ex- 
haustion frjm the nursing before the rheumatism began. Her recollec- 
tion of events which occurred during the first month of her ilhiess is very 
imperfect. 

29f7i Apj'il. — During the past week has gained five pounds in weight, 
and is now cheerful, rational, and says she feels perfectly well. Muscles 

21 



322 RHEUMATIC INSANITY. 

under her control. From that time her recovery was steady and rapid, 
till she was well in mind and body. 

Is any light thrown on the relations between rheumatism, chorea, and 
insanity, or on the connection between motor and psychical abnormality, 
by the case I have related? Was the rheumatism the true cause of the 
mental symptoms, of the chorea, or of both ? Were these abnormal 
affections of motion and the perverted psychical manifestations the result 
of an identical and simultaneous lesion affecting both the motor and 
mental ganglia? Or was the one dependent on the other, secondary to 
it, or sympathetic with it ? Is it not evident that in this case we have a 
distinct form of insanity, a form about which much may be ascertained 
by a careful study of its relation to, and its correlation with, the motor 
symptoms ? It will be observed that nearly all the functions of the 
nervous system were here affected — the nutrition, heat production, motion, 
sensation, reflex action, the special senses, the memory, and the intellec- 
tual processes all at the same time, and they recovered their normal action 
about the same time. 

I think it cannot be doubted by anyone that the rheumatism was the 
true cause both of the chorea and the insanity in this case. All the 
symptoms — the coming on of the disease, the choreic movements, the 
paralysis of motor power, the deadening of reflex action of the legs, the 
hallucinations of sight, touch, and taste, the want of memory, the acute 
delirium with unconsciousness of anything going on around, succeeded 
by confusion of ideas, suspiciousness, and sluggishness of mind, the high 
temperature increased at night, the tendency to improvement in all the 
symptoms coincidently with the lowering of the temperature, and the 
slowness of the convalescence — all these things show that some lesion of 
the central nervous system existed. And when this is taken along with 
the fact that such a train of symptoms suddenly appeared in the course 
of an attack of rheumatism, that the symptoms of the articular rheuma- 
tism at once disappeared, while the fever did not do so, and that in this 
woman, when she was nearly well, rheumatic swelling of the knuckles of 
one hand appeared along with aggravated choreic movements, sleepless- 
ness, and an increase of temperature, we have very strong data, not only 
to conclude that rheumatism was the cause of the nervous and mental 
symptoms, but that here we have a true and typical example of a rheu- 
matic insanity, which must be classed by itself as a special form of mental 
disease — a true pathological entity. 

As to how the nervous system was affected, may we not form a prob- 
able hypothesis ? We know how rheumatic disease, whatever it is, affects 
the other tissues. We know also something of the kind of lesions of the 
spinal cord which are needed to produce paraplegia and the total absence 
of the power of the reflex action, even if we do not know^ fti^ly the 
pathology of chorea or of insanity. In regard to the motor affection of 
the legs, we saw that at first there was violent choreic movement, which 
was succeeded by complete paralysis of motion, no power of reflex move- 
ment, and greatly diminished common sensibility. As the power of 
motion returned, which was in the course of a few days, there were 
hyperaesthesia and a sensation of heat. Does not this sequence of 
phenomena indicate a serious but transitory interference with the func- 



EHEUMATIC INSANITY. 323 

tions of the nerve-cells and fibres in the spinal cord, such as might be 
produced by slight rheumatic inflammation and infiltration of the con- 
nective tissue of the cord, causing pressure on the nerve elements ? If 
the nerve-cells or fibres had been themselves attacked with any inflam- 
matory afiection, they would not have so soon regained their function. 
We know the rheumatic poison has a special tendency to aff'ect the 
connective tissue. The rheumatic pains in the limbs are caused, we 
cannot doubt, largely by simple pressure on the small nerves. And if 
the cord was affected in this way, is it not probable that the same thing 
took place in the brain centres that minister to special sensation, and also 
in the mental portions of the organ ? The raised temperature and the 
strongly acid urine remained the same, whether the rheumatic inflamma- 
tion was in the joints or in the central nervous system. But when the 
inflammation had passed away, the eff"ects were far longer visible in the 
delicate tissue of the nervous centres. 

In this case the insanity might be described as a metastatic one, if 
such a term were strictly applicable to the eff^ects of a poison in the blood 
whose efl'ects are first seen in one set of tissues, and then in another set. 
The slight relapse, when the hand and the spinal cord were both affected 
at the same time, showed, however, that the effects of the toxic agent 
need not be absolutely limited to one sort of tissue. If we believe this 
theory, that of embolism falls to the ground, as an explanation of the 
chorea of rheumatism with or without mental symptoms. There was no 
ascertainable trace of a tendency to heart disease in the case. The effects 
of embolism could not have so soon passed away, even if it is conceivable 
that it could have been universal in* all parts of the brain and cord. 

It would seem that in such a lesion of the spinal cord as occurred in 
this case, the common sensibility was the last to be abolished and the first 
to come again ; then the voluntary motor power returned, then the reflex 
actior, and, last of all, the power of the nerves which preside over nutri- 
tion. That the sensory and motor functions should have been less inter- 
fered with than the reflex action is what might have been expected, when 
we consider that the greater number of the nerve-fibres ministering to the 
two former merely pass through the cord, while the nerve-cells forming 
the ganglia which subserve the latter function, lie in the cord itself. The 
cord was evidently more affected than the brain. 

It was not until all the other functions were restored that the trophic 
function was restored, and the patient gained in weight rapidly. The 
slough that formed over the buttock from the bruise, and the slow healing 
of the wound, showed how much it was affected at first. In regard to 
the special senses, sight was first affected, and then taste, and they were 
restored in inverse order. Of the purely psychical functions, memory 
and the power of voluntary attention were first affected, then the coher- 
ence and balance of the mental powers were upset, and lastly the whole 
of the mental operations were merged in the acute delirium and utter 
incoherence present. Curiously, in all the patients laboring under this 
disease that I have seen, there were suspicions of those about them, and 
entire scepticism as to what they were told about the most simple matters 
during convalescence. Yet there was never in either of them any ten- 
dency to mistake the identity of anyone about them, and one of the very 



324 RHEUMATIC INSANITY. 

first mental acts they performed correctly was to take notice of persons 
about them, and know them again when they saw them. The healthy 
elasticity of mind and enjoyment of life, which is the most certain proof 
that the brain is performing all its functions normally, was the last to 
return, and corresponded to the restoration of function of the centres of 
nutrition, and the commencement of a rapid increase in weight of the 
whole body. 

That was the first case of rheumatic insanity I ever met with, and it 
has been the best ; but I have met with many cases of the same type 
since. One had an attack of chorea in youth, previously suifered from, 
though without rheumatic symptoms. I had one woman in whom the 
disease was very severe, and ended in complete paraplegia and death in 
a few months. I found the cord to have undergone a destructive in- 
flammation and softening in all its columns pretty nearly throughout its 
entire length. 

The treatment of such cases is just the treatment of acute rheumatism, 
with the nursing and care suitable for a bad delirious kind of mania in 
addition. The prognosis is favorable in most cases. On the whole, the 
disease is rare. 

We may have a choreic insanity both in early youth — the common 
time for chorea — and in more advanced life without any acute rheumatic 
symptoms. The delirium is then, as Maudsley points out, of an inco- 
ordinated, jerky kind, like the muscular movements. Such a delirium 
is apt to come in bursts, and to pass away quickly. In the cases of 
chronic chorea the mental affection is often depression at first, then mania 
with impulsive acts of violence or suicide, and then dementia in the end. 
Some of these cases are very sad from the sufierings — mental and physical 
— the patients undergo through their involuntary jactitations. I had a 
man, J. G., who frequently had to be placed in a padded room to protect 
him from the bruisings he would otherwise have inflicted on himself. He 
at last literally wore himself out. One is justified in keeping such cases 
under the influence of chloral and the bromides to decrease their sufferings. 
Sleep in any form, and induced by any means, is to them a blessing, for 
it is the only time they are at rest and peace. 

In many forms of insanity there are choreiform movements that cannot 
be called ideo-motor. I had a case of general paralysis, J. H., in which 
the patient's left hand was always engaged in a rhythmical rubbing of 
his trousers with his thumb and forefinger. I have now a case, J. J., of 
chronic delusional mania, in which the fingers of one hand are rubbed 
over the thumb of the other so constantly in a rhythmical way that the 
cutis of both hands is quite horny ; and, like cases of ordinary chorea, if 
the patient is held still by muscular force, the subjective mental sensation 
is one of pain, which soon shows itself in outward acts. I had a case 
of chronic mania, J. K., a shoemaker, who, during all his waking hours, 
in church or at a dance, except when really shoemaking, went through 
the motor pantomime of pulling his threads through the leather. I have 
now a case of excited melancholia, J. L., a lady, who makes the most 
extraordinary choreiform faces and grimaces in a sort of automatic, un- 
thinking way. She says it is a relief to her to do so. This sort of move- 



GOUTY INSANITY. 325 

ment is common among the insane, and I look on it as being in many of 
them closely allied to chorea. 

The treatment of all kinds of choreic insanity is, first, tonic and nutri- 
tive, and then anti-rheumatic. I have had one or two cases where arsenic 
worked wonders. I have had other cases where the bromides given as 
for epilepsy did good. Iron, too, and zinc, and the valerianates, are all 
good in some cases. Cold to the spine in certain cases temporarily stops 
the movements. 

In the Middle Ages there used to be wonderful epidemics of St. Vitus's 
dance, with mental symptoms that were certainly morbid, affecting at the 
same time thousands of persons by a kind of morbid sympathy and imita- 
tion. Mankind seems less subject to these strange imitative, uncon- 
trollable, mental-motor epidemics now than it was several hundreds of 
years ago. 

GOUTY OK PODAGROUS INSANITY. 

This is a rare disease in forms sufficiently marked to come under 
specialist treatment, or to be regarded as technically mental disease ; but 
mental phenomena due to gout are common enough, and have been 
described by all authors on the subject. Irritability, incapacity for 
mental exertion, and depression are the most common of these. Syden- 
ham gives a good description of them in his classic work on gout. "The 
body is not the only sufferer, and the dependent condition of the patient 
is not his worst misfortune. The mind suffers with the body, and which 
suffers most it is hard to say. So, much do the mind and reason lose 
energy, as energy is lost by the body — so susceptible and vacillating is 
the temper — such a trouble is the patient to others as well as to himself — 
that a fit of gout is a fit of bad temper." The above, no doubt, is the 
most common mental effect of gout, but it does not amount to mental 
disease. Deep melancholia is a common accompaniment of the gouty 
diathesis, especially about the climacteric and early part of the senile 
periods. I have had several cases of intense suicidal melancholia at this 
period of life in patients with a strong gouty heredity and gouty deposits, 
but who had not been subject to the regular acute attacks. I have one 
such case now, J. M., aged fifty-five, with a strongly gouty heredity and 
acquired syphilis, who was always more or less dyspeptic, and suffered 
from constipation. He always had marked psoriasis, and latterly gouty 
deposits on lobes of ears. Before he became affected in mind he fell off 
in flesh, his skin eruption disappeared, he became very costive, and a 
very dilated sigmoid flexure was found to exist. Sleeplessness and strong 
suicidal impulses, with delusions as to his trouble, were the chief charac- 
teristics of his depression, his reasoning power otherwise being good. 
Every kind of medical treatment — anti-gouty, anti-syphilitic, soporific, 
sedative, and tonic — was tried in vain. Nothing really seemed to do him 
good except feeding, with an excess of milk and eggs, sugar and fresli vege- 
tables, given at first by the nose-tube, and living out in the fresh air. He 
got fat and his sleep returned in about nine months, the acute misery dis- 
appearing, and I am not without hope of a recovery of an incomplete kind. 
He gained two stone in weight under treatment — a great nutwtive triumph 



326 PHTHISICAL INSANITY. 

in such a subject. There are signs of slight degenerative tissue changes 
in him in the nerves or nervous centres, or both, evidenced by a partial 
paralysis of the ring and little fingers of the left hand, with wasting of 
the muscles. That of course I do not expect to disappear. Garrod de- 
scribes "gouty mania" as a very acute delirious affection, occurring in 
some patients immediately after the cessation of the acute joint affections. 
Alono; with the mania there are heat of head and fever. In one such case 
which he describes, all the mental symptoms passed off when one toe 
became affected in the ordinary way. This kind of acute gouty insanity 
either terminates quickly in recovery, or runs on to congestion and in- 
flammation of the membranes of the brain. 



PHTHISICAL INSANITY. 

An anaemic brain, from whatever cause, is always prone to disturbance 
of function. Lack of blood means imperfect nourishment. Where we 
have so vascular a tissue as the gray substance of the brain convolutions 
(almost half composed of capillaries), there the blood is needed in largest 
amount and richest quality if we are to have healthy and vigorous men- 
talization. Every one who has experienced any disease that has thinned 
and lessened the blood, has felt the difference in his mental power then 
as compared with health. The physiological effects of depriving the 
brain of part of its blood, or even of lowering the blood pressure down 
to a certain amount, are different in different cases to some extent. In 
this as in other ways in human beings, the strong and the weak hereditary 
qualities of a brain come out. One man merely has singing in his ears, 
a tendency to faintness, or a profound mental lassitude and paralysis of 
volition, amounting almost to torpor ; those being probably the purely 
physiological mental results of a bloodless brain. Another man becomes 
intensely supersensitive and over-excitable, suffering torture from sounds 
and circumstances that in health would have been calmly borne ; another 
cannot sleep ; another has hallucinations of the senses ; another takes 
convulsions, long before that amount of blood is lost that necessarily 
causes convulsions ; and another becomes delirious, or is attacked with 
insanity. The same, or rather far greater differences of brain symptoms, 
result from the diseases and morbid conditions that cause or are specially 
accompanied by anemia. The cachexias, the blood-poisonings, and the 
diseases of nutrition in which blood is not made in sufficient quantity, 
may all be attended with danger to some brain functions, though certain 
brains seem to have the innate trophic energy to nourish their tissues and 
perform their functions on less blood than others. In those predisposed 
by heredity to disturbance or enfeeblement of the mental functions, it is 
the mind that suffers in conditions of bloodlessness. We are entitled to 
assume that the convolutions of such brains have less than the normal 
trophic and functional energy. After death, in such cases, the whole 
brain, but more especially the convolutions of the anterior lobes and the 
vertex, are often found disproportionately anaemic as compared with 
the other organs of the body ; and the brain is not only found anaemic, 
but manifestly wanting in normal consistence, in some cases atrophied to 



PHTHISICAL INSANITY. 327 

some extent, and in others presenting an appearance closely resembling 
the first stao-e of necrosis from brain embolism. In all such cases its 
specific gravity is lessened. Chemical analysis of the brain has not as 
yet reached that point of certainty that it can tell us what constituents 
are specially wanting in such diseased conditions. In patients that have 
been insane, and had pulmonary consumption, I have seen the most 
marked brain anaemia, low brain specific gravity, irregular vascularity, 
and soft brain texture that I have met with, not being cases of " w^hite 
softening " from embolism or other local cause of brain starvation. 

The frequent association of the depraved nutritive condition known as 
"scrofulous" with idiocy and congenital imbecility is well known and 
universally recognized by those who have had experience of such cases. 
The common occurrence of pulmonary phthisis as a cause of death 
among the insane had been long noted by those having charge of the 
older lunatic asylums. A special connection between the scrofulous and 
phthisical constitutions and the insane predisposition had been pointed 
out by Van der Kolk and others. The short attacks of delirium to 
which some phthisical patients are subject had been described by Morel. 
And that mild unreason, the spes phthisica^ had been known from 
classic times. But any special manifestation of mental disorder directly 
connected with pulmonary consumption had not been described till in 
1863 I did so, as the result of a very careful statistical inquiry into the 
matter. I was led to the conclusion that such a connection existed on 
clinical grounds as well as statistical ;^ hence I called the form of mental 
disease Phthisical Insanity. This is not the place to combat the argu- 
ments that have been put forward against the existence of this mental 
disorder. No doubt consumption was startlingly more frequent as a 
cause of death among the inmates of the older asylums than in the 
modern institutions ; but still it is in all asylums for the insane between 
three and four times more common than in the general population at the 
same ages. In the Royal Edinburgh Asylum it has fallen almost to one- 
half in the past ten years under improved hygienic conditions compared 
with the period of 1842-1861. But that has nothing to do with the 
two per cent, of my patients that I classify on admission as phthisical 
insanity on account of their mental and bodily peculiarities, which 
I shall presently describe. 

No doubt brain anaemias of all kinds, and from whatever causes, are 
apt to produce mental conditions like phthisical insanity, and in some 
individual cases, I admit, quite indistinguishable from it. It is said 
that insanity is infrequent in hospitals for consumption. It may be that 
such mental disturbance as would be properly reckoned technical insanity 
is not common in such institutions, but, so fiir as I am aware, w^e have no 
statistics on that question. We have only one person in every twenty- 
one hundred of the general population becoming insane every year ; and 
if one in every thousand of the persons already phthisical became 
insane, that would not bulk largely in the mind of a physician to a hos- 
pital for consumption whose attention was not directed to the matter, 
though it would be an increase of insanity of one hundred per cent. 

^ Journal of Mental Science, April, 1863. 



328 PHTHISICAL INSANITY. 

But the great reason why insanity is not common in hospitals for 
consumption is simply that it usually appears before the lung symptoms 
of the phthisis, and the cases are sent to lunatic asylums instead. 

I have the satisfaction of knowing that many acute clinical observers 
have supported my conclusion that there is a phthisical insanity, Dr. 
Maudsley going the length of saying that he has seen many cases 
exhibiting a phthisical-mindedness not amounting to technical insanity, 
less in degree but the same in kind. 

No doubt my clinical experience of twenty years, since 1863, has 
modified to some extent some of my conclusions of that date. For 
instance, I do not now look on phthisical insanity as being so incurable a 
condition as I did then ; but I had not then had the experience of the 
working of modern hygienic ideas in asylums, or of the most recent 
modes of treating the insane therapeutically and morally. But, on the 
other hand, my experience has strengthened the conviction that a 
phthisical insanity exists, and in the typical cases is well marked in its 
characters, and that it is different in many essential points from any 
of the other forms of anaemic or diathetic insanities. It does not arise 
in asylums through any defects in their hygienic conditions or otherwise. 
The patients labor under it when they come into asylums. Its existence 
and amount have no fixed relationship to the death-rate from phthisis in 
the institution at all, for I find that while in the nineteen years 1842- 
1861, the death-rate from this disease in the Royal Edinburgh Asylum 
was twenty-nine per cent., I estimated in 1863 from the symptoms 
of patients put down in the case-books that for the ten previous years 
about three per cent, of the admissions were cases of phthisical insanity ; 
and in the ten years 1873-1882, when the mortality from phthisis has 
only been fifteen per cent., I have, from my own personal knowledge of 
each case, diagnosed and recorded at the time two per cent, of those 
admitted as suffering from phthisical insanity. Those two things, there- 
fore, so liable to be confounded with each other, the general death-rate 
from phthisis and the number of cases of phthisical insanity admitted into 
an institution, must be put entirely apart. 

The general characters of phthisical insanity are such as might be 
expected to be found in persons of weak vitality. There is no acuteness 
of vigor about the symptoms of the disease. Looked at solely from the 
point of view of the mental symptoms present, some of the cases would 
be called mania of the mildly delusional, slightly demented type; more 
of them would be called melancholia, also of the mildly delusional type; 
and many of them w^ould be called monomania of suspicion. It is a very 
striking fact in regard to the last, that nearly all pure cases of monomania 
of suspicion sooner or later die of phthisis. The symptom of a morbid 
mental suspicion runs through all the cases of phthisical insanity. Some- 
times, but not commonly, they have an acute stage at first, but this is 
always short. Most frequently the disease begins by a gradual alteration 
of disposition, conduct, and feeling in the direction of morbid suspicion 
of those about the patient, a morbid fickleness of purpose, an unsocia- 
bility, an irritability, and an entire want of buoyancy and proper enjoy- 
ment of life. Along with this there are loss of weight, indigestion, 
intolerance of fat, want of enjoyment of food, perversion of taste in 



PHTHISICAL INSANITY. 329 

regard to food, and a bad color of the skin. There may or there may 
not be any chest symptoms present; most frequently there are not. 
Then comes the acutest part of the attack, if there is such a stage in the 
case. The patient gets sleepless and mildly melancholic or maniacal, the 
bodily state running down all the time. The organic enfeeblement that 
characterizes the disease is often shown by refusal of food. The patient 
thinks he is being poisoned, this no doubt being the convolutional mis- 
interpretation of the pain and uneasiness of indigestion. In a way, he 
is often poisoned, for his food is badly digested and assimilated, and the 
subjective sensations accompanying this are not unlike some kinds of 
poisoning. After a little, the patient becomes irritable, sullen, unsociable, 
and suspicious, his state varying from time to time. The intellectual 
processes are not so much enfeebled as there is a disinclination to exercise 
them. There are occasional unaccountable little attacks of excitement. 
The patient is disinclined to amuse or employ himself He looks on any 
attempt to persuade him to do so as persecution, and as being prompted 
by hostile motives. There is some depression, but no intense mental 
pain. The patient associates with no one, and the kindnesses of relatives 
merely call forth reproaches. If the patient lives long, he becomes more 
silent and apparently demented, but he can always be roused out of this 
for a short time. Complete typical dementia does not usually occur. If 
there is any tendency to periodicity, the remissions and aggravations are 
not regular or complete. Bodily he cannot be fattened, he looks sallow 
and haggard, his circulation is poor, his pulse weak, and anything like 
tone is entirely absent. There is no muscular energy, and a strong dis- 
inclination to exertion. The appetite is poor and capricious. Colds are 
taken very easily. The patients lose weight and are all round worse in 
cold weather. The temperature tends to be low until the lungs become 
affected, and then there is an insidious evening rise, which is perhaps the 
only sign of the presence of a bodily disease. In very many of the cases 
— one-half the number, according to my experience — the chest symptoms 
are at first latent even after the lungs have become markedly affected. 
There is no cough or spit or pain. I have often happened to notice that 
a patient laboring under phthisical insanity (and this applies to cases of 
dementia and many cases of acute insanity, too) was breathing a little 
more quickly than normal, or was looking more pinched, or was falling 
off his food, or his pulse was quicker and weaker than usual, or he had a 
hectic-looking spot on one cheek, or his skin felt hot; and on examining 
the chest in consequence of some such indication, I have found extensive 
broncho-pneumonia, or consolidation, or breaking up of the lung tissues. 
The progress of the lung disease varies much in different cases, in some 
being rapid and causing death in a few months, and others going on for 
years if the conditions, food, and hygiene are favorable. I have seen 
such cases in the very feverish stage before death, when the temperature 
rose over 102°, rouse up wonderfully, and even cease to manifest the 
morbid suspicions, but such cases are exceptional. It would seem as if 
in these cases the high temperature and quickened circulation stimulated 
the anaemic and ill-nourished convolutions to increased and almost normal 
mental activity. 



380 PHTHISICAL INSANITY. 

The following is an example of the disease : 

J. N., set. 43. Her previous history was not known very accurately, 
but this seems to have been the first attack of insanity ; it had not existed 
more than a few months. She resided in London, and came to Edinburgh 
to seek her son, who had been dead some time. This she had knoAvn 
before she became insane. No hereditary predisposition was know^n. 
She had been wandering about, and was troublesome, but not violent. 

On admission she w^as apathetic, and, when roused, suspicious-looking, 
not answering questions correctly or even intelligently, but showing her 
insanity much more by her peculiar expression of face and her conduct 
when spoken to than by her conversation. Hair dark, complexion dark. 
She is of the melancholic temperament. She was on admission thin and 
weak, but appeared before becoming insane to have enjoyed good bodily 
health on the whole. 

After being some months in the asylum, her mental state was as follows : 

"She has many delusions, which she only shows at times, and is not 
very consistent in her expression of them. She fancies that she is preg- 
nant, that the foetus is extrauterine, and that she will require to be 
operated upon. She is very suspicious, especially of her food, sometimes 
starving herself through fear of being poisoned. She also at times seems 
to imagine that she has much property that is being kept away from her. 
She is very idle, and cannot by any means be persuaded to employ her- 
self. At times, without any cause, she becomes abusive to those about 
her, and much excited. She remains thin and pale, but takes her food 
well, but has shown no clear symptoms of suffering from any actual lung 
disease. She is unsociable, takes no interest in her friends, does not 
want to get away from the asylum, or at least expresses no wish to do so. 
She gets excited for short periods of a few hours at times, and during 
these attacks of excitement all her symptoms are much worse." 

And in the course of two years her state was the following: 

She is now much thinner and weaker than she was, but no symptoms 
of any disease have manifested themselves, and she refuses to allow any 
examination to be made of her chest. She is more taciturn and less 
seldom abusive, except when she is spoken to or interfered with. She 
never speaks to anyone, except to ask for something she w^ants, resents 
being interfered with in any w^ay, and treats all about her as if they were 
her enemies. When asked about her health she frequently becomes 
abusive, and seems to think some insult or harm is meant her. She is 
never pleasant by any possibility, and never thankful for any attention 
shown her. She distinguishes in no way those who are kind to her from 
those with whom she has nothing to do. At long intervals now she 
becomes excited, abusive to some one who has given no cause for such 
conduct, and she assigns no reason for such abuse. 

She remained mentally as described, but in bodily health became 
weaker, lost flesh, and did not take her food so well, but no cough or 
spit appeared till two months before her death, w^iich occurred after she 
had been in the asylum five years. For two or three years before death 
she had been thin, pale, weak, capricious in her appetite, inclined to keep 
her bed, and evidently laboring under organic disease. She resisted an 
examination of her chest so very strongly that it was never thoroughly 



PHTHISICAL INSANITY. 331 

made. There was never any diarrhoea, but all the other symptoms of 
phthisis were present in great severity for two months before death. 

Post-mortem Examination. — The brain was atrophied, anaemic, and 
oedematous. The white substance composing and surrounding the fornix 
and septum lucidum was almost diffluent. The left lung was everywhere 
infiltrated with masses of tubercle, each tubercular spot soft in the centre. 
The cavities so formed were many of them evidently very old. The 
upper lobe of the right lung was in a similar condition. The mesenteric 
glands were enlarged and tubercular. The mucous membrane of the 
caecum and ascending colon was ulcerated, thickened, and red. 

Commentary on such a case is almost superfluous after what I have 
said about phthisical insanity. A woman has a family, and lives till she 
is forty-three. She then becomes insane, never having very acute symp- 
toms, suspicion^ irritahility^ unsociability^ with causeless, unaccountable 
exacerbations, and a want of interest in anything, being the chief symp- 
toms. She is thin and in weak bodily health when she becomes insane, 
and although having good food and fresh air never gets stronger. She 
becomes weaker, paler, and thinner gradually, until she is exhausted and 
very weak, and then a severe cough and spit comes on two months before 
she dies. Can anyone doubt that in this case the insanity was contem- 
poraneous in its appearance with the preliminary symptoms of tubercu- 
losis, that the ordinary symptoms of the latter disease were obscured by 
the state of the brain, and that it was the tuberculosis, and not the 
insanity, that kept the patient thin and weak bodily ? And do not the 
mental symptoms resemble in some degree those of an exhausted man 
whose brain has been starved of a ^sufficient supply of nourishment by a 
disabled stomach, an exhaustive discharge, or unsound lungs? 

J. 0., set. 31, a joiner. Father had been insane. Had led a dissi- 
pated life at times. Had always made his living at his trade. Was 
married, and had a family. The first symptoms of insanity were noticed 
more than a year ago, and he was then sent to an asylum, but having 
apparently quite recovered, he was discharged. He was never quite well 
after this, however. He was unsettled, would not work at his trade with 
any one master for more than a few weeks at a time. He accused his 
wife of poisoning him, of conspiring against him, and of getting her 
relations also to plot against his life. His having been in an asylum at 
all he attributed entirely to their desire to get rid of him for then- own 
purposes. 

On admission into the asylum he was generally quiet, reserved, and 
suspicious in look and manner, without showing much suspicion in his 
words. He was a man in average health, with a fair complexion, dark- 
brown hair, and a more than usually intelligent face. He was very 
reticent about his delusions. 

For some time after admission he wrought in the joiner's shop, but 
then began to fancy that his working there kept him in the asylum, and 
refused to work any longer. He became more unreserved in his expres- 
sions of dislike and suspicion of his wife and her relations. He might 
often be seen to exchange his own dish for that of his next neighbor at 
meals, when he could do so without attracting much attention. He 
looked as if he "knew all about it" when asked about this proceeding, 



332 PHTHISICAL INSANITY. 

but would give no explanation of it. He evidently had strong prejudices 
against the head male attendant, and shook his head and laughed, and 
said, "You know very well," when asked why he disliked this man. At 
one time he became so well that his discharge from the asylum was con- 
templated. 

He had not been in the asylum six months till he had slight haemop- 
tysis, and when his chest was examined the presence of tubercular disease 
was indicated by dulness on percussion, and crepitation on auscultation 
at the apices of both lungs. He said, however, that he had often, before 
he came into the asylum, spat blood. Shortly afterwards, his condition 
was the following: 

"He now w^orks in the joiner's shop only when he is almost obliged 
to do so. He often requires to be told that he will be carried out if he 
will not walk. He does not need to work hard, and is only asked to 
work at all for his own sake, because when he is employed in any way 
he is much happier and more content than when quite idle. He some- 
times abuses the head attendant in most unmeasured language. He 
imagines he is the heir to large estates, and is kept here a prisoner by 
his wife's relations to exclude him from his inheritance. No amount of 
persuasion will convince him that this is not the case. He is suspicious 
of almost everyone round him ; he tries to exchange the portion put 
before him at every meal for that of some one else. He is at times very 
irritable, and gets much excited. He took cod-liver oil for some days, 
but then imagined it was poisoned, and refused to take it on any account. 
He is constantly asking for changes of diet, and when he gets them he 
remains as dissatisfied as before. He is still pretty strong, and is in good 
condition; but complains, when at work, of shortness of breath. It is 
not for this that he refuses to work, however ; he imagines that it will be 
the means of keeping him longer here. His most common question to 
the reporter every day is, "When will this have an end?" referring to 
the conspiracy which he imagines is being formed against him. At times 
he is entirely reticent, merely shaking his head significantly when asked 
how he is — " Oh, you know well enough, why ask me ?" 

A year after admission he was attacked with a cough and spit, and his 
difficulty of breathing became increased, and he was no longer asked to 
do any work. He got much worse mentally immediately after he was 
allowed to be quite idle. He could never be induced to take any kind 
of medicine for more than a day or two, and the extra diet and stimu- 
lants ordered for him were almost forced down his throat. The lung 
disease advanced rapidly. He became worse every week, while his sus- 
picions and irritability became the cause of more and more misery to 
him. He gasped reproaches against the medical officer, as he sat cough- 
ing and breathless, for giving him the medicines intended to relieve him. 
Everything that was done for him he imagined to be for a sinister purpose, 
everyone who was kind to him he suspected of being an enemy, and all 
the symptoms of his disease he believed to be caused by his food or 
medicine. All his symptoms were as severe, when they once had fairly 
commenced, as in ordinary cases of phthisis among the sane. 

To the last he retained his delusions unchanged. He died within 



PHTHISICAL INSANITY. 383 

eighteen months from the time of his admission. He was much ex- 
hausted, but not quite emaciated, when he died. 

Post-mortem Examination. — The brain was on the whole almost 
normal, except that the arachnoid was very milky, and the pia mater 
infiltrated with opaque serum, while the lining membranes of the ven- 
tricles were thickened and, in the anterior part of the lateral ventricles, 
covered with small granulations. 

The lungs were both almost entirely infiltrated with tubercle. This 
tubercle was very hard, however, except in some softened spots. It was 
intermixed with the fibrous pneumonic lung, and, as was seen from the 
appearance of some of the vomicae, as well as the , consolidated fibrous 
lung, the organ had been aifected for a long time. The cavities and the 
densest parts of the tubercular deposit in both lungs were at the bases. 
There was no ulceration of the caecum or colon. The mucous membrane 
of the stomach and duodenum was of a very dark color and very soft. 

This is a good example of those cases of monomania of suspicion, 
almost all of whom, according to my statistics, die of tuberculosis. The 
insanity was strongly hereditary. 

Such are the main and typical features of phthisical insanity, and the 
foregoing are good examples of the disease. Certain general questions 
arise in regard to it for answer. Are all cases where we have phthisis 
among the insane apt to be of the mental type I have described ? No, 
only those, in my opinion, who have had the well-known bodily symp- 
toms of the pretubercular stage of phthisis. The most marked cases are 
those with a hereditary tendency to both phthisis and insanity, or to the 
neuroses. It is surprising how often both diseases occur in different 
members of the same family. No physician in extensive practice but 
has met with very many such families. They are too frequent to be a 
mere coincidence. The constitutional weakness which tends to end in 
phthisis is, I have no doubt, akin in some degree, under some conditions, 
to that which tends to end in insanity. If one function of the brain is 
to govern the trophic processes of the body, and if that organ is strongly 
predisposed to go wrong in its mental functions in any case, it stands to 
reason that the law of the solidarity of action of the whole organ will 
come in, and that the nutritive processes will often be affected also, and 
the recuperative and resistive power lessened. Daily experience among 
the insane shows us that this is so. As I said when speaking of the 
nature and treatment of melancholia, thinness is its bodily essence and 
almost constant accompaniment, and fatness its natural cure. So in 
regard to that special tendency to depraved or weakened trophic energy 
that speedily tends to end in lung disease, if it is not cured it tends to 
affect the nutrition of the brain, and the result is phthisical insanity. 
Ascertainable hereditary predisposition to insanity exists in seven per 
cent, more of the cases of phthisical insanity than in the insane generally. 

Which disease begins first as an actuality ? The insanity in most 
cases, undoubtedly. In most instances it exists several years before any 
discoverable lung trouble appears, just as there are many persons who 
have all the premonitory symptoms of phthisis long before the lungs are 
affected. I am not now entering into the (Question of the different forms 
of phthisis, or the modes in which the lungs are affected, or into the 



334 PHTHISICAL INSANITY. 

specific germ theory of tubercle. By the phthisis I speak of, I mean 
that typical form where there has been a marked constitutional tendency 
to malnutrition and lung disease, that form, in short, which is usually 
hereditary, and always has far more symptoms than the mere lung 
disease to characterize it. The mode and time at which the lungs are 
affected by actual disease are accidents due to special circumstances, such 
as exposure to cold. 

In regard to the question whether insanity is not sometimes cured by 
the advent of lung disease, I confess I have never seen any real instance 
of it. I have seen many cases where patients brightened up, and were 
less melancholic and far less torpid after the temperature rose through 
aggravation of lung disease, and I have seen this occur repeatedly in the 
same case as the inflammatory process became active. But the improve- 
ment was only apparent, and was always transitory. It simply resulted 
from the increased temperature and more active circulation in the brain. 
Any disease that produces those conditions will have the same effect. 

A very interesting question arises as to the effect of phthisis on the 
mental condition of sane persons. There is the universally recognized 
spes phtJusica^ and there is often also a mental brilliancy, short and 
fitful like the light of an ill-supplied lamp, and there are delirious, leth- 
argic, and confused times, in different cases. In very many there is a 
fancifulness, a causeless changing from hope to despondency, an inca- 
pacity for continuous thought, that seems to characterize this disease 
more than other chronic ailments. Doctors do not see these things 
so much, for at their visit the patients pick themselves up mentally ; but 
ask nurses and relatives who are with such persons all the time, and they 
will tell you of many small mental peculiarities of sane phthisical patients. 

In order to exhibit the results of my experience in regard to phthisical 
insanity for nine years 1874-1882 inclusive, in a statistical form, I have 
gone carefully through the case-books of the Royal Edinburgh Asylum. 
Each case was diagnosed as to its clinical mental type within the year of 
its admission. This is perhaps too soon in this form of insanity, for, as I 
mentioned, some of the patients have a regular maniacal and melancholic 
attack to begin with, of short duration, before they settle down. The 
general result was this : During those nine years there have been thirty- 
one hundred and forty-five admissions. Of these, eighty-five have been 
diagnosed as phthisical insanity. This is 3.7 per cent, of the cases 
admitted. Following out these eighty-five cases, I find that twenty-six 
have been discharged recovered. This is a recovery rate of thirty per 
cent. The recovery rate in the asylum during the same period has been 
forty-six per cent. This would show, supposing my diagnosis to have 
been correct, that cases of phthisical insanity recover, but in much less 
proportion than the average of patients sent to the asylum, which include, 
it must be remembered, many general paralytics, paralytics, dements, and 
other cases, hopeless from the beginning. The recovery rate among the 
patients admitted with no recognizable organic brain disease, and who 
had been less than a year insane before admission, w^as at least seventy 
per cent. We may say, therefore, that the cases diagnosed as phthisical 
insanity recover in much less than half the proportion that cases of 
insanity uncomplicated with brain disease do. In order that this propor- 



PHTHISICAL INSANITY. 335 

tion of phthisical insanity should recover, special treatment — dietetic, 
moral, and medicinal — is required to combat the depraved general and 
brain nutrition present. 

I next inquired into the death-rate from tubercular complaints among 
the eighty-five phthisically insane patients. Up to this time eighteen 
have died of phthisis, but it must be taken into account that in addition 
to the twenty-six who recovered there were thirty-two cases removed from 
the institution not recovered mentally, some of these being taken home to 
be nursed by their relations during their last illness — to die, in short. 
Bnt more than the eighteen will die of phthisis, for those admitted in the 
recent years have not yet had time to develop the complaint, and some of 
them are now phthisical. The general result is that eighteen out of the 
twenty-seven who were not recovered or removed have already died 
of phthisis. 

I next examined into the general statistics of phthisis in the institution, 
quite apart from phthisical insanity, for the same period of nine years. 
Eighty-three cases died of this disease in that time. There having been 
altogether six hundred and thirteen deaths in the time, this w^as at the 
rate of 13.5 per cent., or one in seven. Of all the deaths from phthisis, 
therefore, 21.7 per cent., or just over one in five, had been originally 
diagnosed as phthisical insanity. Looking at the other clinical forms of 
insanity who died of phthisis, none of them approach in number the 
phthisical insanity. Seven cases of epileptic insanity died of phthisis 
and seven cases of general paralysis (though the large number of this 
disease who died of phthisis, I think, is much more than the average), 
and five cases of adolescent insanity, but beyond these no special variety 
was found in the phthisical list. 

In going over those patients who had died of phthisis I had an oppor- 
tunity of seeing a clinical fact in regard to the effect of the development 
of phthisis in one or two cases on a previously existing insanity. In 
such patients it often had the efiect of producing a mental condition 
similar to the symptoms of phthisical insanity in patients who had not 
labored under such mental symptoms before. Such patients became 
suspicious, sullen, irritable, and unsocial, some of them being also melan- 
cholic. One young man, J. P., who had been a cheerful, active fellow^, 
sociable, and constantly playing the piano and singing, became moody, 
suspicious, impulsive, and irritable just before his chest was found to be 
affected, and while he was getting thin, not taking his food, and looking ilL 



LECTURE XIV. 

UTEKINE OR AMENORRHCEAL, OVARIAN, AND HYSTERICAL IN- 
SANITIES—THE INSANITY OF MASTURBATION— UTERINE OR 
AMENORRHCEAL INSANITY. 

No doubt the influence of woman's great function of menstruation is 
considerable on her normal mentalization. It has a psychology of its 
own, of which the main features generally are a slight irritability or 
tendency towards lack of mental inhibition just before the process com- 
mences each month, a slight diminution of energy or tendency to mental 
paralysis and depression during the first day or two of its continuance, 
and a very considerable excess of energizing power and excitation of 
feeling during the first week or ten days after it has entirely ceased, the 
last phase being coincident with woman's period of highest conceptive 
power and keenest generative nisus. As is well known to all physicians, 
many purely nervous derangements and diseases, such as neuralgia, 
migraine, epilepsy, and chorea, are apt to be aggravated at the menstrual 
periods or to begin then. There are often perversions of tlie great in- 
stincts and appetites then. In some women the social instincts are then 
partly suspended, and in others there are perversions of the appetites for 
food and drink. Dr. Halliday Croom has kindly given me the notes of 
two such cases. One young lady patient of his at every menstrual 
period pulls out and eats the bristles of the hair-brushes in her own 
room, and sometimes goes into other rooms for more brushes for the 
same purpose. He has another lady patient, married, set. 36, who, for 
fifteen years, has eaten at each menstrual period salt, dry oatmeal, and 
bits of sponge, and has been none the worse for this. I have met with 
(and what physician has not?) cases of women who had intense cravings 
for stimulants and narcotics at each menstrual period, and indulged those 
cravings, to their intense disgust and regret sometimes afterwards. Dr. 
Croom gives me the notes of a case where the craving was for malt liquors 
only. 

The regular and normal performance of the usual functions of the 
uterus and ovaries is of the highest importance to the mental soundness 
of the female. Disturbed menstruation is a constant danger to the 
mental stability of some women; nay, the occurrence of absolutely 
normal menstruation is attended with great risk in many unstable brains. 
The actual outbreak of mental disease, or of its worst paroxysms, is co- 
incident with the menstrual period in a very large number of women 
indeed. It does not follow from this, of course, that the menstruation 
caused the insanity in all such cases. The constant difiiculty the physi- 
cian has is to know whether the disordered or suspended menstruation is 
a cause or a symptom. Nearly all the acute varieties of insanity disturb 



UTEKINE OE AMENORRHCEAL INSANITY. 337 

or suspend menstruation in women while the acute symptoms last. I 
find that attendants on the insane do not expect menstruation to be 
regular, if present at all, in cases of acute mania or of intensely excited 
melancholia. I also find that among the women patients in an asylum, 
taking them throughout, chronic and acute, the occurrence of menstrua- 
tion is apt to cause an aggravation of the morbid mental symptoms 
present. The melancholies are more depressed, the maniacal more rest- 
less, the delusional more under the influence of their delusions in their 
conduct; those subject to hallucinations have them more intensely, the 
impulsive cases are more uncontrollable, the cases of stupor more stupid, 
and the demented either more enfeebled or tending to be excited. In 
the chronic insane, whose home the asylum is, and its regulations and 
routine their rules of life, we frequently find the menstrual periods a 
time when their subjection to the asylum discipline is not so absolute as 
usual, and their conformity to the ways of its daily life is not so un- 
varying. Of course, there are a great many exceptions to this in the 
chronic insanity of women, to whom the menstrual period makes no 
difference whatever. Those are usually patients affected with quiet, mild 
dementia, who work hard and are in good bodily health. At times we 
see special directions taken by those menstrual aggravations of mental 
disease, such as an accentuation of the emotional perversions that exist, 
an excitation of the amatory feelings towards the opposite sex, a stimula- 
tion of the habit of masturbation, or the occurrence of stupor and con- 
fusion in the whole of the mental processes. The last (stupor) is ex- 
ceedingly apt to occur in young women during adolescence about their 
menstrual times. I have now a patient, eJ. Q., of nineteen, usually a 
bright, active girl, who, for about a week or ten days at her menstrual 
periods, becomes confused, stupid, and depressed — her face and whole 
muscular movements showing an extreme hebetude and slowness. Some 
few melancholic patients get maniacal at the menstrual periods; and I 
have seen a case of acute mania cease to be excited, and become depressed 
and fearful during menstruation. 

Taking the mass of the more chronic and quiet cases of insanity, I 
find that menstruation is just about as regular as to time, and as normal 
in the amount of discharge lost, as among a similar number of average 
sane women. A very considerable number of female lunatics have the 
delusion that they are occasionally ravished by men at night, and this is 
usually more intense after menstruation. 

But apart from these general effects on all kinds of existing mental 
disease, of disordered or suspended menstruation, insanity in some few 
cases actually results de novo from this as an exciting or predisposing 
cause. Those cases may be conveniently termed uterine or amenorrha?al 
insanity. Most of them, two-thirds at least, are melancholic in character, 
the mental symptoms following the amenorrhoea, and passing away when 
regular menstruation returns. 

The following is a typical case of this sort: J. R., ret. 20, of a neu- 
rotic but not an insane heredity. Comes of an " excitable" family. Had 
gone from a country district and farm work to domestic service in a city, 
where, after a year or two, she fell off in general health, and ceased to 
menstruate. She at once became depressed, took morbid end depressing 

22 



338 UTERINE OR AME^"ORRHCEAL INSANITY. 

views of religion, was forgetful, confused, and sleepless, and lost her. ap- 
petite. She wept without cause; was very obstinate, misinterpreting 
the object of our giving her medicine, making her work, walk, and keep 
herself tidy. She said she should be out of the world and was not fit to 
live, but never attempted suicide. She was ordered, and made to take, 
iron and aloes, with much fresh air and fattening diet. She o;ot worse 
at first, and hallucinations of hearing developed. She distinctly heard 
voices telling her she was the worst person alive. She would have re- 
fused food had she been allowed to do so. In about two months she 
began to improve in body and mind, especially in bodily looks and weight. 
For three months longer she remained depressed, and then menstruated 
after a series of hot baths and mustard to her feet. She brightened up 
from the first day of menstruation as if a cloud had been lifted oif her 
mind, and she kept well ever after. 

In such a case I do not think it was the amenorrhoea alone which 
caused the melancholia. Both were in reality the result of a running 
down in health and vitality, but no doubt the mental symptoms were 
greatly aggravated by the suspended menstrual function. I do not think 
the melancholia would have been cured by a restoration of menstruation, 
had that been possible, before the blood had become richer and the nutri- 
tion improved. In fact, I have seen the coming on of the menses under 
these circumstances aggravate the mental symptoms, the case assuming 
during menstruation a maniacal form. The treatment of such cases 
should therefore be directed at first towards improving the general health 
more than towards restoring menstruation merely; at all events, until 
the nutrition of the body is improved. Then the usual means for re- 
storing the menstrual function should be resorted to, and when they are 
successful, or when, as most frequently happens, nature restores the 
function, the mental improvement is often as marked and immediate as 
in J. R.'s case. It will be observed that some amount of improvement 
took place in her mental state as the bodily nutrition improved before 
menstruation returned. 

The melancholic cases, of which this of J. R. is the type, nearly all 
recover, in my experience. Out of twenty-four of very typical form 
which we have had in the Royal Asylum in the past nine years, eighteen 
have recovered. 

About one-third of the amenorrhoeal cases were maniacal, with no 
melancholic tendency. Such cases were by no means so clearly con- 
nected with the absent menstruation as even the melancholic ones, nor 
did they show the same tendency to recover in mind coincidently with 
its restoration. In fact, I was by no means so sure of the same kind of 
direct connection between the amenorrhoea and the mental symptoms in 
most of them as in the melancholic cases. 

It is commonly supposed that the sudden suppression of menstruation 
in a young, full-blooded, healthy woman of nervous heredity, through chill 
or shock, is very liable to cause an outburst of acute delirious mania. 
Some authors speak of this as if it were one of the common causes of 
insanity. No doubt it occurs, but I have not met with more than two 
cases in all my experience. One was that of J. S., a girl of eighteen, 
stout, florid, and healthy, who got wet through and chiUed while men- 



OVAKIAN INSANITY. 339 

struating. The flow suddenly stopped, and at once a fearful headache 
came on, with maniacal delirium, a temperature of 103°, sleeplessness, 
and very great violence. A hot bath, with cold to the head, and with 
enormous doses of bromide of potassium, borax, and ammoniated tincture 
of valerian, frequently repeated, had the effect of diminishing the de- 
lirium and reducing the temperature. A condition of semi-stupor and 
confusion, inactivity and listlessness succeeded, and lasted for two months, 
when the usual mental health was regained, but it was several months 
before menstruation was restored. I should say that stupor is a more 
common mental result of suppressed menstruation in young women with 
a nervous heredity than acute mania. 

OVARIAN INSANITY — ''OLD MAID'S INSANITY." 

There is a somewhat ludicrous form of insanity that Dr. Skae called 
" Ovarian," or more familiarly and more correctly, I think, "Old Maid's 
Insanity." There is really no definite proof that the ovaries are either 
disturbed in function or diseased in structure in those cases, but it con- 
sists no doubt of a morbid transformation of the normal affectiveness of 
woman towards the opposite sex. The disease usually occurs in unpre- 
possessing old maids, often of a religious life, who have been severely 
virtuous in thought, word, and deed, and on whom nature, just before 
the climacteric, takes revenge for too severe a repression of all the mani- 
festations of sex, by arousing a grotesque and baseless passion for some 
casual acquaintance of the other sex whom the victim believes to be 
deeply in love with her, dying to marry her, or aflame with sexual passion 
towards her, or who has actually ravished her after having given her 
chloroform. Usually her clergyman is the subject of this false belief. 
Out of ten such cases which I can recall, seven have had clergymen as 
their supposed wooers or seducers. In no case was there the very 
slightest possible ground for the notion. In two cases the ladies had 
never even spoken to their supposed lovers. Certain gestures, or, as in 
one case, the contents of the agony columns of the newspapers, were 
sufficient proof to them of their beliefs. The annoyance to which un- 
fortunate men are subjected in this way is often extreme. Lately a ladj, 
J. T., now a patient of mine, went to a grocer's shop and ordered her 
supply of groceries in the name of a clerical acquaintance, saying she was 
his wife, telling the shopman to send the bill to him, and this as the cul- 
mination of a series of weekly letters to him of forty pages each. I have 
known grave accusations made to ecclesiastical authorities, and the be- 
ginnings of most injurious famas started by such insane women. Such 
patients are all of them between thirty-five and forty-three, and the 
reverse of sensuous in appearance. Some of them were most estimable 
ladies, whom it was impossible not to pity, the whole thing was so con- 
trary to the tenor of their lives, and so like a trick played on that higher 
being which they had always cultivated, by «. lower and more animal 
nature which they had sedulously repressed None of them recovered 
from this sort of delusion, but in two of the cases, as they passed into the 
senile period, and after the climacteric, the notion became so theoretical 
that they almost ceased to allude to it. 



340 HYSTERICAL INSANITY, 



HYSTERICAL INSANITY. 



That form of mental disease which is complicated with some of the 
protean symptoms of hysteria should really be dklled ovarian insanity, if 
that name were used in any correct sense, for there is but little doubt 
that undue excitation or disturbance of the functions of the ovaries has 
more to do with hysteria than anything else. But perhaps it is more 
convenient to retain the name of hysterical insanity. Typical hysteria, 
pure and simple, always has a mental complication. The volition, or the 
feelings, or the morals, are always aifected along with the purely bodily 
symptoms. But these mental symptoms, not forming the chief features 
of the disease, or not being of such a nature as to make the patient irre- 
sponsible or unmanageable, are not reckoned as being of the nature of 
technical insanity, at least among the rich. Among the poor, with no 
one to look after them, hysterical young women are often enough sent to 
asylums. And I have seen most admirable results from this. The 
principles of asylum life and treatment are the very best principles of 
treatment for hysteria too. To put the patient under control, to give 
her no harmful sympathy, to make her work and walk out regularly, to 
improve her bodily health, are ahvays very good for a hysterical girl. 
We have had three cases of almost typical hystero-epilepsy, with a sui- 
cidal tendency in two of them, and general unmanageability at home in 
the third, in addition to the purely motor and other symptoms, sent to 
this asylum within the past few years, and I have not seen or heard of 
any home or hospital treatment so effective as the asylum treatment 
proved to be in these girls.^ But such patients are rare in asylums. The 
usual type of case classified as hysterical insanity consists of mania or 
melancholia in a young woman with one or more of the following char- 
acteristics well marked, viz., a morbid ostentation of sexual and uterine 
symptoms, feigned bodily illness to attract attention and secure sym- 
pathy, marked erotic symptoms cloaked by something else, a morbid 
concentration of mind on the performance of the female functions, semi- 
volitional retention of urine, hysterical convulsions, a morbid wayward- 
ness, ostentatious and unreal attempts at suicide. The fasting girls, the 
girls with stigmata, those who see visions of the Saviour and the saints 
and receive special messages in that way, the girls who give birth to mice 
and frogs, and those who live on lime and hair, are all cases of this 
disease. 

Hysterical symptoms are exceedingly apt to occur in the insanities of 
puberty and adolescence, and along with those symptoms the habit of 
masturbation is common. It is sometimes difficult, therefore, to know 
whether to classify such cases as adolescent, hysterical, or masturbational 
insanity. All one can do is to ascertain if the hysterical symptoms are 
the most marked and prominent features of the case before we call it 
hysterical insanity. 

The following case of hysterical insanity fairly illustrates the general 
features of the disease. 

^ Two of these are recorded by Mr. T. Inglis in the Edinburgh Medical Journal, 
December, 1878. 



HYSTERICAL INSANITY. 341 

J. U., aet. 21, of a nervous and excitable temperament; habits correct. 
An aunt epileptic. Had on one occasion at home a mild attack of what 
must have been subacute maniacal excitement. The cause of the present 
attack, which has lasted for four days, was a fright which first produced 
ordinary hysterical symptoms, and then maniacal symptoms engrafted on 
them. She shouted and screamed, spoke of hearing God speaking to 
her, and would rush to the window to jump out. She imagined she was 
a most important person, attitudinized and did everything to attract at- 
tention to herself. Attention and sympathy were craved by her, and if 
she could not get them in one way she tried another. She refused her 
food, saying it was poisoned, but took it rather than be fed with the 
stomach-pump. She had menorrhagia, and was most minute and cir- 
cumstantial in the details as to her female health. She was tried with 
hyoscyamine, valerian, and mono-bromide of camphor with apparent 
benefit; but I considered the greatest improvement was produced in her 
case by discipline, work, open-air exercise, tonics, and good plain food in 
abundance. She improved at first, and once or twice relapsed, but in 
two months she recovered and was discharged. I do not like to keep 
hysterical cases too long in the asylum after convalescence as a general 
rule, for they sometimes get too fond of the place, preferring the dances, 
amusements, and general liveliness of asylum life, even with its restric- 
tions, to the humdrum and hard work of poor homes. 

The following very characteristic letter of a maniacal hysterical girl, 
J. v., very well illustrates the trains of thought in such a case :^ 

"My Dear Mamma. — It is time that I leave to return home. I have been 
tremendously changed for the better. I think papa will be able to get me a com- 
mission under Garibaldi before long. There are three to whom I am especially in- 
debted — one Mr C, the modeller, the other the doctor, a Eunuch, who modelled me 
at the fire, and attended on me and bathed me. He is I am sure a gentleman, a 
splendid doctor. Could not papa get him into a regiment abroad ? And there is the 
nurse. Could not papa get him any situation away from Morningside Asylum where 
I am at present ? I should like papa to come for me as soon as possible. Do you re- 
member the verse, " There are," &c. (12th verse 19th chapter of Matthew). About 
Eunuchs ? Then I beg to inform you that according to Scripture and my conscience, 
Jessy, your cook, is a man ; and Janet, the mad devil is a man ; and D. and H., boys 
who can have children. Aunt I. is a man, and yourself also, both made of men, and 
I am a boy, made of Dr C. and Dr Z. Mrs T. is a man, made of men. They are 
very ignorant on this subject here ; but as for me it is certain that at least the spirits 
have showed me, which Christ sent when I was under drugs ; they showed me this. 
I have at times since I came here passed the shadow of death, and therefore am 
authorised to speak in opposition to all men and women, gentlemen and ladies who 
oppose me. I am, I can I swear, as you want to know what sex I belong to, a 
mixture of a nymph and a half-man, half-woman, and a boy, and a dwarf, and a 
fairy. I know more than my fellow mortals, having expired eleven times before the 
time. — I am, &c." 

Our statistics of hysterical insanity show a good proportion of re- 
coveries. In the nine years, 1874-82, there were thirty-four female 
patients so classified, and of those who were treated to the termination 
of their malady sixty per cent, recovered. 

1 " Morisonian Lectures " for 1873, by Drs Skae and Clouston, Journal of ]N[ental 
Science, vol. xix. p. 500. 



342 THE INSANITY OF MASTURBATION. 



THE INSANITY OF MASTURBATION. 

The unnatural gratification of the sexual appetite through masturbation, 
it must be admitted, is very common among boys and lads. Especially, 
we believe, among lads of the educated classes, brought together in the 
somewhat artificial if not unnatural life of our public schools, does it 
prevail. I believe that the more healthy and more stolid country lad, 
the son of the farm laborer, is not so apt to indulge in this unnatural 
and disgusting practice as the son of the professional man, supposing 
each to be initiated in the same way. Boys are taught the habit, and 
begin to practise it, often long before they know or can know the real 
difierence between sexual good and evil. But a healthy constituted lad 
in body, mind, and morals does not tend to come under its influence to 
any very hurtful extent. His natural organic repugnance to it strengthens 
as he grows up. If he is fortunate enough to have a home, or access to 
family life, his lower instincts are transformed and elevated into the normal 
social instincts, through the gratification of which they find a natural and 
pleasurable outlet. 

But the habit of masturbation, in certain other cases, acquires a power 
that is dominating and destructive to body and mind. The causes of this 
are, either an innate morbid strength of the reproductive instinct, or much 
more frequently an innate weakness of the controlling faculties, or of a 
lack of inherent brain stability, or of an incapacity of organic repugnance 
to what is unnatural. Such weaknesses are apt to occur in the children 
of neurotic families. From the beginning the habit is apt to take a deep 
hold of such youths, who practise it to the point of exhaustion of all 
nervous energy. Even when this occurs, and when in a healthy subject 
satiety would have caused disinclination and incompetence in the youths 
to whom I refer, the practice is not stopped. The weaker and more 
nervous he gets the more he indulges in the evil habit, till the point of 
absolute break-down of body and mind is reached. It seems to get pos- 
session of him like an evil spirit, and to dull and paralyze all his better 
feelings and his natural instincts. The heredity and temperament are 
no doubt the true explanation of the opposing statements that are con- 
fidently made, on the one hand, that this habit seldom does much per- 
manent harm, and, on the other, that it is the root of most of the evils of 
boyhood, and that it ruins the constitution for life of everyone who has 
ever indulged much in it. Both statements are so far true of boys of 
difi'erent constitutions and heredity. It is somewhat like drinking to 
excess ; many persons can do this at times without risk of dying the 
death of drunkards, but others cannot do so without that distinct risk. 
It is no doubt true that the restraint and management of the reproduc- 
tive instinct give most youths most trouble, and, as medical men, the 
priests of the body and the teachers of the truths of medico-psychology 
and physiology, we can often help them by our counsel and our knowl- 
edge. Unfortunately, our help is too seldom called in. We are about 
the only persons who can help a youth to strike the happy mean between 
blissful but dangerous ignorance and prurient suggestive knowledge. We 



THE INSANITY OF MASTURBATION. 343 

are the only persons who can judge from the constitution of the particular 
individual how much he ought to know, and what risk he runs. 

As a complication and symptom of almost every form of insanity, the 
habit of masturbation is lamentably common. The melancholic, the 
maniacal, and the demented patients are all subject to its indulgence. 
The religious ecstatics who have direct intercourse with the Almighty, 
and the suicidal melancholies who have committed crimes beyond re- 
demption — many of such patients of both sexes are masturbators. In 
fact it is, as it might be expected to be, a common sign of the loss of self- 
control which is the essence of mental disease. When practised to excess 
by the insane, it certainly tends to aggravate mental exaltation, to in- 
tensify depression, to lead directly towards mental ehfeeblement, and to 
make impulsive tendencies more violent. It counteracts the effects of 
treatment, it induces relapses, and in some cases prevents the recovery 
of otherwise curable cases. These bad results are most frequently and 
clearly seen in the adolescent, hysterical, puerperal, epileptic, and con- 
genital forms of insanity, and, curiously enough, are not always absent 
in the climacteric and senile forms. I have seen a senile melancholic of 
seventy-five suffer intensely from the effects of the practice. In all these, 
however, it is one of many symptoms of mental disease. It is not the 
chief cause, nor is it the chief symptom present, and it does not color the 
cases so as to give them any distinct mental features. 

There is a form of mental disease, however, in which masturbation is 
the chief cause of the malady ; it is the chief symptom present, and it 
gives the whole case distinct features. This has been named the insanity 
of masturbation, and has several well-marked features. It comes on in 
youth ; it generally begins by an exaggerated and morbid self-feeling, or 
by a shallow, conceited introspection, or by a frothy and emotional re- 
ligious condition, or by a restless and unsettled state, with foolish hatch- 
ings of philanthropic schemes. There is no continuity or force in any 
train of thought or course of action. Then comes a melancholic stage of 
solitary habits, disinclination for company, especially that of the other 
sex, irritability, variableness of mood, hypochondriacal brooding, vacilla- 
tion, and perversion of feeling towards near relations. Suicide is often 
thought of, and oftener talked of, but masturbation makes most of its 
victims too cowardly to kill themselves. Then an acute attack follows, 
usually of a maniacal kind. This may end in recovery, or may run 
quickly mto a dementia that is masturbational in character, being soli- 
tary, unsocial, and subject to impulses, sometimes homicidal — a sort of 
masturbational hyperkinesia — all these being incurable. 

With these mental symptoms there are usually well-marked bodily 
signs of the disease. The patient is thin, pale, and pasty, with a cold, 
clammy skin, a haggard face, and an eye that never looks straight at 
you. The patient has weakness in the back, pains in the head, palpita- 
tion of the heart, impaired sight, muscular relaxation, and sometimes 
spermatorrhoea. But for a complete record of the feelings and symptoms 
of the youthful masturbator one should rather go to those shameful quack 
advertisements put into the country newspapers than to medical books. 
They are there set forth at large, with just enough concealment to make 
them suggestive. That such abominable suggestions of evil should be 



344 THE INSANITY OF MASTURBATION. 

allowed to be scattered broadcast into the families of decent people, is to 
me one of the standing marvels of our jurisprudence. They do and can 
do no good to anyone ; they aggravate the miseries of those who are 
suffering from the minor effects of this vice by keeping them constantly 
before their minds ; they suggest evil thoughts to those who might be 
free from them, and they fatten the vilest of mankind. I verily believe, 
and I speak from some experience, that there are about as many people 
made insane by these advertisements and the pamphlets sent out by the 
advertisers, as by the habit of masturbation itself. 

No greater condemnation of the habit of masturbation can be imagined 
than the changed feelings towards the other sex which it produces. 
Nature there as elsewhere punishes the breaker of her laws. Such perver- 
sions of feeling are very interesting to the medico-psychologist. Instead 
of the true, healthy pleasure, intense as it is natural, of social and family 
intercourse, there comes a self-conscious bashfulness, a painful conflict 
between desire and repugnance, a suspicious constraint, and a guilty 
avoidance. The evil to him who evil thinks is seldom more marked than 
in the case of the masturbator. Any method through which this habit 
could be lessened among our rising generation would certainly do great 
good; life would be elevated in a large degree, self-respect would be 
increased, social intercourse would be sweetened and its pleasures inten- 
sified ; while the stings of self-accusation and remorse would be far fewer 
in after-life. 

~ The ordinary type of masturbational insanity is illustrated in many 
of its chief features in this case : 

J. W., set. 22, a young man of a naturally cheerful and frank disposi- 
tion and steady habits, and with a good family history so far as known. 
When an infant he was delicate, and was supposed to have been threatened 
with hydrocephalus, and he had convulsions during his first dentition. 
Those symptoms no doubt implied a neurotic heredity. Since then his 
health had been good up to his present malady. For years after puberty 
he indulged in the habit of masturbation to a great excess. He gradually 
fell off in looks and bodily vigor, and mentally he became changed. He 
got egotistical, hypochondriacal, changeable in his resolutions, fanciful, 
and unsocial. Those symptoms did not come on all at once, but took 
years fully to develop. They seemed to follow a diminution of nervous 
tone and general bodily strength. At last the mental depression stood 
out from all the other mental symptoms. It was hypochondriacal in 
character. He thought his sexual organs were "all gone," that his chest 
was "falling in;" he complained of pains in his back and in his head, 
and that his back was "very weak." When he was about twenty-two 
he made several feeble ineffectual attempts to commit suicide, both by 
hanging and strangulation. He was then sent to the asylum. He was 
pale, his muscles flabby, his sj^in moist and clammy, his tongue coated, 
his bowels costive, and his expression depressed and furtive. He never 
could look one in the face. Masturbators seldom can ; but do not put 
down every insane person who cannot look you in the face as necessarily 
a masturbator. His genital organs w^ere loose and flabby, and his testicles 
tender. He says he suffers from spermatorrhoea, but has now no natural 
sexual desire. Yet his mind runs on the subject, and it is one of the 



THE INSANITY OF MASTURBATION. 345 

great sources of his mental depression that he has lost his virility. He 
thought himself very weak indeed, and that he could not get better. He 
said he would like to put an end to himself, and yet would not like to do 
so. He was ordered compound cod-liver oil emulsion with hypophosphites, 
strychnine, much milk diet, fresh air, cold sponging, and a little garden 
work. He was never done making attempts to strangle himself with his 
necktie. In about three months he was distinctly improved. His whole 
"tone" of mind, general nervous action, and of nutrition, was better. 
But he could scarcely be prevented from talking about himself and his 
ailments, imaginary and real. He wanted medical books to read about 
his case, and said he had bought and read all the quack literature on 
"nervous depression," etc., he could lay his hands on, which always 
made him worse. He ate and slept well, and, it was feared, continued 
his evil habit, but not to any great extent. In six months he had gained 
in weight, could employ himself more, and was much more cheerful. He 
was sent home half-cured, on the theory that he would there have more 
motives to rouse himself and go to work. That he did, and after a year 
he was pretty well. 

Here is the extract from a very instructive letter to me from J. X., a 
lad of twenty-two, who for two years had been hypochondriacal and un- 
settled, and alternately elevated and depressed in mind: "If I had come 
like a man to the point, and told the doctors what was the real matter 
with me (but in fact I really did not know myself till some time ago). I 
have committed masturbation for some years back, and sometimes as often 
as three times a day. I am sure I cannot explain myself nor give account 
of such conduct. Sometimes I felt so uneasy at my work that I would 
go to the W.C. to do it, and it seemed to give me ease, and then I would 
work like a hatter for a whole week till the sensation overpowered me 
again. I have been the most filthy scoundrel in existence. I did not 
know at that time what harm I was doing myself, although I knew I was 
doing something filthy and wrong, and many are the times I have made 
resolutions to put a stop to such conduct, and sometimes managed for a 
month, not more. Owing to my trade I fell in with lots of girls, but 
never cared much about speaking to them, owing, I believe, to me doing 
that filthy practice." He describes how he tried to have connection with 
a girl with whom he thought he had at last fallen in love, and that he 
failed, and that he was disgusted with himself and her. " This and other 
things, with my business not getting on, I was most determined to end 
my miserable career." He then described how he took laudanum, and 
how he felt afterwards. "I hope for my father's sake you will give me 
your advice, not for my sake, for I am not worth taking notice of. Some 
time ago, when I was wondering if there was any seed left in me at all, 
I committed masturbation, but had to do it for a considerable time, and 
after some did come it was dull in the color and scanty, and instead of a 
pleasant sensation it pained me." After a month or two this lad's de- 
pression passed oif, and as his bodily health improved he became ex- 
citable, restless, egotistical, and irritable. This lasted for a time, and he 
then appeared to get quite well in mind and body. 

I have known many instances of the habit of masturbation being taken 
to without any teaching, and in some cases at incredibly early ages. I 



346 THE INSANITY OF MASTURBATION. 

have now a patient, J. Y., who is always nervous, diffident, unable to 
earn his own livelihood, tending to be depressed and suicidal at times, 
and egotistically irritable, conceited, and impracticable. At other times, 
every now and then, he gets so depressed that he has to be sent into the 
asylum, or comes into it of his own accord. This man has frequently 
assured me, when at his best mentally, that he acquired the habit when 
he was six years of age, that no one taught him, that almost ever since 
it has been his bane and curse, that he knows as well as anyone how 
wrong it is to practise it, and that it does him infinite harm in body and 
mind ; and he says that at times his mind is filled with disgust at the 
filthy nature of the practice, and despair at the hold it has acquired over 
him. Yet, in spite of all this, he cannot stop it, the morbid fascination 
over his mind is so powerful. He describes it as like a fate that he must 
yield to, an involuntary act over which his will seems to have no control, 
though the practice of it is at times painful and not pleasurable. Yet I 
never saw any case in which suitable treatment, control, fresh air, hard 
work in the garden, and suitable food, had so good an efi"ect. After two 
or three months he became another man, lost to a great extent his hang- 
dog look, his depression, his suspicions, and hypochondriacal notions, got 
fresher and fatter, and had less marked inclination towards his evil habit. 
But it has unmanned him, and made him quite unfit for facing the world. 
So anxious was he to be cured, that he has had himself castrated lately. 
This has stopped the tendency to masturbation, but mentally some de- 
pression and "nervousness" remain. 

There is no doubt that the act of masturbation is often not only done 
involuntarily and contrary to every inclination of the will, but it may 
also be unconsciously done. I have seen it done in the unconscious period 
immediately after an epileptic fit ; and in the unconscious stages of acute 
mania and excited melancholia it is most common. 

Many of the cases do not recover. I have many patients in the 
asylum, of which this is a type: K. A., aet. 37. Began to masturbate 
at fifteen, and has continued the practice to excess ever since. He became 
so insane as to require to be sent to the asylum at tAventy, after a year or 
two of restless egotism and selfish hypochondriasis, varied by spurts of 
equally selfish emotional religionism at home. He at first could reason, 
read, and occupy himself a little, but as the habit has gone on his mental 
power has gradually weakened, his social instincts have become extin- 
guished, his self-respect and all his sense of decency have become utterly 
lost. He is now a slouching, untidy-looking fellow, wdth a hang-dog 
look, who can never be got to look you in the face, who never reads or 
speaks to anyone, cares nothing for his relatives, has no energy, looks 
pale, red-nosed, and pinched. And yet he is not quite demented in the 
ordinary sense. He is coherent, and you find his memory is not gone 
when you talk to him. 

The general principles of treatment of masturbational insanity unques- 
tionably are to brace up the youth bodily, mentally, and morally. In 
the first place, the diet should be unstimulating and fattening. It is 
strange that the physiological inductions of the old Catholic Church as 
to the dietetic management of the nisus generativus and its volitional 
control have been so neglected by modern physicians, founded as they 



THE INSANITY OF MASTURBATION. 347 

were on the experiences of the terrific conflict with nature that was 
implied in the early Christian theory that sexual desire was more or less 
of the devil, and should be eradicated and not merely regulated by all 
men who wished to attain a high religious ideal ; and in the later rule of 
priestly celibacy. My own belief is that the Catholic view of repression 
and eradication being, for the sake of argument, granted, almost every 
rule of the church as to food and fasting, and every practice of the mon- 
astic orders, and every conventual regulation, is a correct physiological 
principle. Translated from religious into physiological language, they 
may be summed up thus — Strengthen the power of inhibition bodily and 
mental. Practise the habit of mental concentration and abstraction from 
certain lines of thought. Cultivate enthusiasm about ideals. Find ideal 
outlets for the afi'ective and social faculties other than sexual choices. 
Sleep only under such conditions and so long as to recuperate lost energy 
and tissue, and not to accumulate energy that there might be a difficulty 
in getting rid of short of sexually. Eat only non-stimulating and fat- 
tening food, and that in moderation, with periodic abstentions to use up 
spare material in the body. Avoid flesh, as the incarnation of rampant, 
uncontrollable force, sexual and otherwise. Be much in the open air, 
and work hard. Finally, so fill up and systematize the time that none 
is left for day-dreaming. Now, such are undoubtedly the proper rules 
with which to treat the habit of masturbation and its mental and bodily 
efiects. If we add to those the medical means of cold baths, tonics, 
games, family life, and a course of bromide of potassium, our resources 
are pretty nearly exhausted. I would certainly avoid local treatment or 
mechanical appliances as a general rule. It is no doubt possible to make 
the organs of generation so so're that excitation of them becomes im- 
possible ; and if the patient's imagination has disappeared through his 
dementia, this rest from constant nervous exhaustion may be taken 
advantage of to feed him up and get him into habits of working, and 
into a comfortable dementia. That is a good thing, but it only applies, 
in my experience, to those whose mental power is already gone. For 
the masturbator whose mental energy is still there to some extent, or 
only temporarily suspended, such mechanical expedients and obviators 
of present indulgence only concentrate the attention on the function, and 
cause desires that are intense in proportion to the present impossibility 
of gratifying them. Do not recommend marriage as a remedy. It is a 
most dangerous experiment. It is apt to be followed by sexual repug- 
nance in a short time, and the last state is worse than the first, two 
persons' happiness being destroyed instead of one. 

There have been forty-six cases that I have diagnosed as masturbational 
insanity sent to the Royal Edinburgh Asylum during the past nine years, 
and of these sixteen, or twenty -five per cent., have made good recoveries, 
doing their work in life well afterwards. Some of the cases I have been 
consulted about out of the asylum, and some of those I have had under 
my care in it, are now occupying responsible positions and doing first-rate 
work in the world. Some are the fathers of fixmilies. There is no ground 
whatever for such an unfavorable prognosis in any case I have met 
with as some medical men in the habit of giving, and there is no sort of 
ground for thinking there is any special risk of relapse, or any special 



348 THE INSANITY OF MASTURBATION. 

form of nervousness, that will necessarily stick to a masturbator all his 
life. Eighteen more of the cases left the asylum more or less improved, 
while twelve still remain there hopeless, incurable, and degraded. 

One warnino; I have to o;ive before I have done with this disao;reeable 
subject. It is this : not to believe all the melancholic patients who 
attribute their bad symptoms to the former practice of this vice in youth. 
This is a common self-accusation. In most instances it is a mere delu- 
sion, like so many other melancholic delusions, founded on a morbid 
exaggeration of the consequences of departures from strict rectitude. It 
just amounts to the same thing, psychologically, as such common melan- 
cholic fancies that the loss of control over the temper, and calling a 
friend a bad name ten years ago is an unpardonable sin, that not going 
to church on a certain Sunday will be punished by eternal damnation, or 
that a gonorrhoea in youth has so polluted the blood that all the offspring 
are diseased, and that death must ensue. The real significance of mas- 
turbation in each case must be carefully inquired into, and the facts 
ascertained before a conclusion as to its effects is formed. 



LECTURE XV. 

PUERPEKAL INSANITY— LACTATIONAL INSANITY— THE 
INSANITY OP PREGNANCY. 

Childbikth, nursing, and pregnancy in women are liable to act as the 
exciting causes of attacks of mental disease. In importance and 
frequency they stand in the order in which I have placed them. Eor 
many reasons it is especially necessary that the general practitioner of 
medicine should be well acquainted with these forms of insanity, for 
they all occur at a time when he is apt to be attending the patient 
for other reasons, they all can under favorable circumstances be treated 
at home in many individual cases, and it is well so to treat them when 
possible. They are all very curable forms of mental disease, and, when 
cured, they are not apt to leave any traces of mental weakness or 
obliquity behind. The patients can resume their work and places in the 
family and society, and be as if they had never been ill. The three 
forms, though having much in commom, yet differ in so many respects 
that I must take them separately. 

The advantage and the practical necessity of classifying mental 
diseases in other ways than accoi^ding to the mental symptoms present, 
are especially seen in these three forms of mental disease. To know that 
a case is one that has begun after recent childbirth is to know far more 
about it than to know it as mania or melancholia for treatment and for 
prognosis. There is no practical physician but will admit this. 



PUERPEEAL INSANITY. 

I do not know any event that can occur in a family, short of death, 
that is so great a shock to all who have to do with it, as for a new-made 
mother of a first-born child to become suddenly maniacal, and require to 
be sent to an asylum. One of the most joyous times of life is made full 
of fearful anxiety, and the strongest affection on earth is then often 
suddenly converted by disease into an antipathy ; for the mother not only 
"forgets her sucking child," but often becomes dangerous to its life. 
And few things are more pleasant than to see the restoration of the 
mother back to all that makes her life worth having. 

Puerperal insanity is technically limited to the mental disease that 
occurs within the first six weeks after confinement. By far the majority 
of the cases, and by far the most acute and characteristic cases, occur 
within the first fortnight. It is a very common form of mental disease, 
for five per cent, of all the cases of insanity among women are puerperal, 
and I think that it is a low estimate that one in every four hundred 



350 PUEKPERAL INSANITY. 

labors is followed by it. In one-half of the patients the disease begins 
within the first week after confinement, and in three-fourths of them within 
the first fortnight. In regard to the cause of the disease, therefore, it is 
definite and clear. The accompaniments of childbirth produce it. The 
great physiological cataclysm itself, the pains of labor, the excitement 
mental and bodily, the exhaustion, the loss of blood, the open bloodvessels 
liable to absorb every septic particle, the sudden diversion of the stream 
of vital energy from the womb to the mammae, these together or separately 
are the causes that, acting on an unstable brain hereditarily, set up one 
of the most violent mental storms that the physician has ever to treat. 
And it comes on very suddenly in most cases. The mother looks self- 
absorbed and dull. She does not take such notice of the baby as is usual, 
or such interest in what is going on. She does not answer questions 
readily. She does not eat, and she does not sleep at night. Next 
morning she is restless. Her eyes are brilliant. She seems to have no 
sense of exhaustion. She expresses foolish fancies, such as that she is 
poisoned, that there is some one under the bed. She takes a violent 
dislike to the doctor, or the nurse, or the child. She begins to chatter 
all the time, and her talk becomes less and less connected. She is erotic, 
joyous, scolding, and perfectly incoherent all Avithin a few hours. She 
gets violent, and needs to be held in bed ; impulsively and without set 
intent she attempts suicide, or tries to kill her baby, or to throw herself 
out of the window. She seems as if she had a supernatural strength. 
Yet when you feel her pulse it is weak and thready, her face looks 
haggard, her temperature has risen to 100° or more, her womb is tender 
on pressure over the abdomen, and she will not look at food. Her lochia 
have first become somewhat offensive and then stopped. Her skin is 
moist and clammy. She soon ceases to know those about her, calls her 
friends by other names, and strangers by the names of her friends. Her 
lips and tongue show signs of getting dry. If she is poor or cannot get 
plenty of nursing or medical attendance, she must be sent to the nearest 
asylum, and the sooner the better, for she needs all that the asylum can 
do for her. She needs to be fed at once, nolens volens (by means of the 
rubber nose- tube if she will not take it otherwise), with plenty of milk 
and eggs, and soups, and wine, and this needs to be repeated every hour 
or two. Let her alone, and she dies or becomes demented. Narcotize 
her with morphia, and her secretions dry, her tongue gets furred and 
hard, and her antipathy to food is doubled. But nurse and feed her well 
by night and day, striking the happy mean between undue restraint and 
too great activity, get her out for a little in the open air in a day or two, 
keep up the attendance, and in a week she will show a little sign of 
mental coherence, in a fortnight her appetite will have returned, her pulse 
will be stronger, her temperature will have fallen to normal, and she will 
walk out herself without tearino- her clothes or throwins; herself about. 
In a month she will be knitting a stocking, and will know her friends 
when they come to see her. Within three months she is well — a joyous 
mother, in her right mind, clasping her child, the whole of the disturbed 
mental period seeming like a dream to her, that is very soon altogether 
forgotten in her new duties and delights. 

Although puerperal insanity is more frequent in first than in subsequent 



PUERPERAL INSANITY. 351 

confinements, yet it is common enough in the latter, and I have known a 
woman, K. B., who had six attacks of puerperal insanity, having one 
after the birth of each child she had, and she recovered from them all. 
But this is the exception. The woman that cannot have a baby without 
having also puerperal insanity, and who persists in having babies, usually 
remains more or less permanently affected after the third or fourth attack. 

The ordinary causes of mental disease contribute as predisposing causes 
towards puerperal insanity. Poverty and w^ant of proper attendance 
during childbirth, and having to get out of bed and to work too soon, I 
have seen bring it on. The shame and mental distress usually attending 
the birth of illegitimate children make it twice as common then as after the 
birth of legitimite children. I have several times seen a sudden mental 
shock act as the proximate cause of the disease in women who seemed to 
be doing well in childbed. I once saw the news of the death of the 
patient's father send a woman, in the second week after confinement, into 
acute mania within a few hours. But such moral or other causes are 
not at all necessary to produce the disease, over and above the puerperal 
condition. In by far the majority of the cases there is no other cause. 
It occurs in ladies with every comfort and attendance as well as among 
the poor. 

Most of the recoveries from puerperal insanity are gradual ones. We 
do not commonly find those sudden wakenings up from an acute delirious 
condition into coherence, self-control, and sanity that we sometimes see in 
other forms of mental disease. That is, in my opinion, one of the reasons 
why the recoveries are apt to be complete and permanent. I do not like 
very sudden recoveries in any form of mental disease, because they are 
not so apt to be permanent, and they indicate an essentially unstable 
dynamical condition of the convolutions. I am never quite satisfied 
about the recovery of a puerperal case until the woman gets stout and 
strong, and until her menstruation has returned and become regular. 

The following is a typical case of puerperal insanity of the acute but 
not delirious kind: K. C, aet. 19, a hard-working domestic servant, with 
no known heredity to the neuroses. Though she came of a " respectable" 
family, she had an illegitimate child born in the Maternity Hospital. Her 
labor was not specially severe, and she did well for three days. Then, 
without any new cause, she got dull and took no notice of her child or of 
anything else; in a few hours she began to laugh hysterically, then she 
got more excited, restless, noisy, and talked incoherently about religious 
matters. She did not sleep, and in four days she had to be sent to the 
asylum. On admission she was much excited and greatly exalted in 
mind. She mistook the identity of everyone near her. She sung on at 
the pitch of her voice in a rhyming way, putting her delusions and con- 
versation with herself into rhyme. Her ideas and currents of thought 
were always changing. She looked pale. Her pulse was weak, and her 
temperature was 98.2°. She did not sleep for the first week at all. She 
was restless, singing, loquacious, and delusional all that time. She was 
put on all sorts of very nourishing food, especially custards of milk and 
eggs, and she was taken out into the open air for a short time each day 
after the first two days. She began to sleep in a Aveek, and after that 
slept more or less regularly. She continued restless, good-natured, and 



352 PUERPERAL INSANITY. 

talkative, destructive to her clothes at times, foil of boisterous, half inco- 
herent fun, and unable to settle to do any work for two months. She 
gained in weight all that time, eating well and spending much time in 
the open air. Then she began to work, was put to rough scrubbing and 
laundry work, so getting rid of her excessive muscular energy. In three 
months she was fattening, quieting, and working hard. In four months 
after admission she was stout, sensible, and well in mind and body, 
menstruation having begun, and she was then sent back to her situation, 
which had been kept open for her in consideration of her previous good 
conduct. 

Some of the very acute cases with a high temperature and most un- 
favorable symptoms make good recoveries, if proper treatment is adopted 
soon enough, as in this case: 

K. D., ^t. 27. A married woman of correct habits, with no known 
heredity to insanity; her first child. Her labor was natural. Things 
went on well for a week ; then, without apparent cause, she began to 
complain of headache and costiveness. She got restless and sleepless, 
then next day she became foolishly talkative and erotic, and neglected 
the child. The lochia and milk stopped. She refused food absolutely, 
getting worse day by day, and becoming weaker fast. She wanted a 
razor to cut her throat, and threw a tumbler at her husband, but was not 
very suicidal or dangerous. In two or three days she was absolutely 
delirious and incoherent, but was not sent to the asylum till seven days 
after the mental symptoms appeared. On admission, she was greatly 
excited, shut her eyes tightly, singing and swearing, and using the most 
obscene language continuously. She seemed to imagine she was in hell 
and surrounded by devils at one time, and she had exalted fancies at other 
times. She did not sleep at night, and with the utmost difficulty was got 
to take some little liquid nourishment. Her temperature was found to 
be 100°. Her pulse was very thready, her skin clammy. She was 
constantly jerking and throwing her limbs about, her tongue tending to 
be dry, and her general bodily condition one of great exhaustion. She 
got ten grains of ohloral and slept three hours the first night. Next day 
she Avas fed by the nose-tube with a custard containing three eggs, one 
pint of milk and cream, some strong beef-tea, four ounces of port wine, and 
five grains of quinine. This acted as a soporific, and she slept well most of 
the afternoon. After awaking, she was less excited, but confosed in 
mind. This mode of feeding was continued twice a day. On the fourth 
evening after admission her temperature was 103.8°, but mentally she 
seemed to have a lucid interval, being rational, and she then took her 
food. Some fetid lochial discharge made its appearance at this time. 
Weak carbolic vaginal syringing was used. On the sixth day she be- 
came again acutely maniacal, with a morning temperature of 101.4°, an 
evening temperature of 102.8°, and she had to be fed with the tube. On 
the eighth day she was sleepy and quiet, took her food, and after two days 
of confosion of mind got quite sane, and remained so, remembering 
nothing of what had taken place during her illness. I allowed her 
friends to remove her on the twenty-first day, she having a good home, 
where her bodily strength could be got up as well as in the asylum, and 
she has kept well ever since. 



PUERPERAL INSANITY. 353 

Puerperal insanity is that form of mental disease in which we are least 
apt to have relapses after the patients have once fairly become convales- 
cent; and I have less hesitation in letting relations remove them from 
the asylum at an early period, if they have good homes and attendance, 
than in any other form. In this case of K. D., I looked on the feeding 
at once as having saved her life. The immediate sedative and soporific 
effects of filling the stomach with food and stimulants were most striking, 
and I very often see this. There is no doubt whatever in my mind that 
alcoholic stimulants along with food are of the utmost service in many 
cases of puerperal insanity, their good effects being more immediate, in 
my opinion, than in any other form of mental disease. 

In the case of patients being attacked with puerperal insanity who 
have good homes, especially if they are in the outskirts of a town or in 
the country, and can get constant medical attendance and good trained 
nursing, they may often be treated at home. I lately attended a lady in 
consultation, K. E., who, within ten days after confinement, became 
sleepless and restless, took antipathies to her doctor, monthly nurse, and 
child, mistook the identities of all those about her, calling me by the 
name of an old friend, who had a temperature of 101°, with slight 
uterine tenderness and absolute refusal of food, being most troublesome 
and difficult to manage. I sent a first-rate attendant from the asylum in 
addition to the ordinary nurse and servants, and she was fed, controlled, 
nursed, taken out, and got through her attack in about six weeks, just as 
well as if she had been sent to an asylum. But the strain and responsi- 
bility on relations, attendants, and nurses were no doubt most severe, and 
they were nearly exhausted by the time the patient had recovered. 

The following case had a melancholic character throughout, though 
acute and curable: K. F., set. 23. No heredity ascertained. Had been 
a strong healthy young woman, and had had one child previously eighteen 
months ago. This child took a convulsive attack within a week after ber 
second confinement, and the fright and shock of this seemed at once to 
upset her mentally, for she was within a few hours afterwards incoherent 
and maniacal. She was put under chloroform, and got morphia in quan- 
tities, and was kept under the chloroform almost continuously for a week. 
This deadening of the brain functions did not cure the maniacal condi- 
tion ; whenever she awoke she was as bad as ever. But next week she 
was almost sensible. After that the acutely maniacal condition returned, 
and after a week of it she was sent to the asylum. She was then 
intensely depressed, looking afraid of something going to happen to her, 
imagining that something was in the bed. Her memory was gone. She 
did not know her husband, and mistook the identity of the people about 
her. She had hallucinations of hearing. Her pulse was 120, feeble and 
intermittent. Her temperature 104.2°. Altogether she was very ex- 
hausted. She was fed hourly with custards and sherry in large quantity. 
On the second day after admission, her temperature suddenh^ sunk to 
97.2° and her pulse to 78, and this was coincident with the appearance 
of a profuse bloody lochial discharge. Mentally she was also much 
improved, though not quite rational. Towards evening she became rest- 
less, and had the hallucinations of hearing again, though her temperature 
was only 98°. She did not sleep, and was very depressed and restless 

23 



354 PUERPEKAL INSANITY. 

next day, saying she was a great prodigal and a sinner, but took food 
voluntarily, though needing forcing to take enough. The temperature 
never again rose above 100°. She frequently showed the morbid brain 
tendency of repeating a w^ord said in her hearing over and over again, 
e.g., Zachariah-iah-iah-iah — Zach-ire." She was well fed and nursed, 
and usually slept about three or four hours a night. In a week she was 
able to be taken out into the garden, and slept much better after this. In 
ten days, had small abscesses forming round one or two of her finger- 
nails. This "critical" symptom — not at all uncommon in cases of recent 
maniacal and melancholic condition — seemed to do her general brain 
condition good. She passed in a month into a quiet, lethargic, rather 
suspicious state, and still depressed, but with no intense mental pain, and 
no delusions expressed. Then she got into the state that is very common 
before recovery in patients in asylums — one of discontent, of increasing 
instant desire to "go home," inability to understand that anything has 
been wrong, or that further treatment away from home is required. I 
have ten times the trouble with my patients — and sometimes with their 
friends — in this stage, for the chief symptoms of the disease have passed 
off, and the patients seem rational. She was dull and suspicious in the 
mornings, and quite well sometimes in the evenings. All this time she 
was gaining in flesh and color and strength, walking much, drinking 
much milk, and being encouraged to employ herself in the house. In 
three months she was sent to our sea-side house, and had sea air and sea 
bathing, both of which did her much good. By that time she had gained 
a stone in weight. In four months, she menstruated for the first time, 
the last cloud of depression passed away, and she was sent home quite well. 

The following is a typical case of puerperal insanity dying of sep- 
ticsemia, or a case, more probably, of puerperal fever with maniacal 
symptoms : 

K. Gr., set. 23, of a cheerful disposition and good habits. Sister and 
aunt have been insane. Has been married between four and five years, 
and has had four children in that time, all born dead, all the labors being 
difficult on account of a deformed pelvis. Had been weak during all the 
last pregnancy, and had pains in the head for two months before delivery. 
Premature labor was induced about the seventh month, with a view of 
saving the child and making her labor more easy than the others had 
been. In a day or two after delivery she began to see faces on the wall, 
to think that the chairs were alive, and that people were whispering 
slanders about her. She did not sleep, and would not take food. She 
got rapidly worse, becoming quite maniacal, delirious, and unmanageable. 
She imagined poison was put into her food, and wanted to rush away 
from home. On admission she exhibited a combination of intense ex- 
citement in paroxysms, during which she required three attendants to 
hold her in bed, with extreme prostration and weakness between. Her 
pulse was thready and 156, temperature 102°, respirations 60. There 
was an anxious look, with great pallor of countenance, when not excited. 
There was evidence of congestion of both lungs, with pneumonia at the 
bases. There was no evidence of tenderness on pressure over uterus. 
No lochial discharge. She was fed with brandy and custards on admis- 
sion, and every hour thereafter, getting ten grains of quinine every two 



PUERPERAL INSANITY. 365 

hours for the first eight hours. In spite of all that could be done she 
sank on the sixth day, the temperature having kept up all the time to 
between 101.4° and 103.8°, the lung symptoms getting worse, and the 
intense delirious excitement coming on once or twice eve^y day except 
the last. 

On post-mortem examination I found the brain intensely congested, 
and the lungs pleuritic, very congested, and almost hepatized at bases. 
But the chief seat of disease was in and round the womb. There was a 
thin layer of pus on its peritoneal surface. There was a small abscess in 
the right ovary, which seemed to occupy the position of a recent corpus 
luteum. The uterus was large and flabby (about six inches by three 
inches), its substance on section containing much purulent matter all 
through it, but especially towards the mucous membrane in the fundus. 
The mucous membrane was thickened and covered with yellowish purulent 
matter, and some of the remains of the placenta were adherent. One of 
the uterine veins on the right side, for about four inches in its course 
towards the vena eava^ was unusually enlarged, looking like a bit of 
very small intestine, its coat thickened, and its lumen filled with thick 
grumous pus. 

It is difiicult to say whether this was a case of " puerperal insanity" 
with septicaemia, or "puerperal fever" with maniacal delirium. I think 
the latter is the more correct description. It was, I think, evident from 
the post-mortem appearances that there was septicaemic puerperal fever 
from the beginning, and this occurring in a weakened anaemic brain pre- 
disposed to insanity no doubt produced the maniacal symptoms. 

I had this year a case of puerperal insanity, K. H., dying in four days 
of meningitis, which came on twelve days after the premature birth of an 
illegitimate child. On admission to the asylum, two days after the be- 
ginning of her illness, she had a temperature of 103.2°, a pulse of 128, 
respirations ^Q per minute, intense exhaustion and collapse, muscular 
subsultus and constant moving about of her hands, a low, muttering de- 
lirium, with no memory, no power of attention, and no coherence. She 
gradually sank on the second day, her temperature rising to 104°. This 
whole condition had arisen suddenly, and developed at once into great 
intensity. After death there was found inside the dura mater a loose 
membrane containing numerous spots of hemorrhage, the surface having 
a yellowish, sticky look. This extended all over the base of the brain. 
The lining membrane of the fourth ventricle was granular. On the 
auriculo-ventricular valves of the heart there were roughnesses with 
tough clots covering them. The womb and its appendages were normal 
for the period after delivery. In a case with such post-mortem appear- 
ances I was a little suspicious of syphilitic infection, considering the pre- 
mature labor and the meningeal appearances after death. 

I have gone carefully over the histories of all the puerperal cases that 
have been sent here during the past nine years. They were all under 
my own care, and the histories were taken on a uniform plan of my own 
by the assistant physicians. There were seventy-five cases altogether 
counted as puerperal, but fifteen of these were either old cases not sent 
in for periods over a year, or the same cases admitted twice during the 
same attack. These I omitted as having no clinical value. The re- 



356 PUEEPERAL INSANITY. 

maining sixty, on analysis and study of their characters and clinical 
symptoms and results, form a very instructive physician's lesson. Looking 
at their ages, it seems as if the disease occurred in just about the frequency 
that ordinary confinements occur at the same ages.^ Forty-four of the 
cases had never been insane before. 

In addition to the puerperal state as the great exciting cause of the 
disease in those sixty cases, I found that there existed as a predisposing 
cause a heredity to insanity in twenty-two of the forty-nine cases in 
which this point could be ascertained. No doubt heredity played a 
much more important part than this if the facts could have been accu- 
rately ascertained, but this is above the average of the ascertained heredity 
in our asylum tables for the same nine years. Moral causes acting during 
the puerperal state were common, such as the deaths of children, desertion 
of husband, frights, etc. The incidence and importance of such causes of 
the disease are best shown by the fact that in thirteen, or twenty-five 
per cent, of the cases, the children had been illegitimate. The average 
rate of illegitimacy in Edinburgh is about one-third of this. Severe post- 
partum hemorrhage, or difficult or instrumental labors, had occurred in 
at least ten cases. But all these causes leave a considerable proportion 
of the cases where there was no exciting cause at all, except a normal 
labor and its accompaniments. 

Looking next at the question of which confinement the disease oc- 
curred most commonly after, I find that twenty cases, or one-third of the 
whole, occurred after first confinements. This is of course out of all pro- 
portion to the number of first confinements in the population. The 
remaining two-thirds happened, some in each confinement up to the 
eighth. This merely confirms what was well known before, ih^i primiparce 
are most subject to the disease. Then as to the period of occurrence after 
confinement. In eighteen cases this was not precisely ascertained, but in 
nearly all these it was within the first fortnight. Of the remaining forty- 
two cases the disease began within the first week in twenty-one, and in 
eleven more within the second week, so that we may say that in eighty 
per cent, of the cases it began within the first fortnight. If that period 
is passed, it is clear that the chief risk is over in a woman in childbed 
from this disease, the first week being by far the most liable to its inva- 
sion. At least half the cases occur then. Only one case of the sixty 
occurred after the twenty-eighth day. 

The next point is very important clinically. Of the sixty cases no 
less than forty-three were very acute in character and symptoms, while 
seventeen only were mild and without acute symptoms. Twenty-nine of 
the forty-three acute cases were generally maniacal in character, and 
fourteen generally melancholic with motor excitement, some of each of 
these classes changing from one state to the other at times. In the mild 
cases the prevailing character was mental depression, fourteen of the 
seventeen being so. In at least eighteen of the acutely maniacal cases, 

1 From 15 to 20 years of age in 3 cases. 
a 20 " 25 " " 16 " 
" 25 " 30 " " 20 " 
" 30 " 35 " " 9 " 

" 35 " 40 " <' 12 " 



PUERPERAL INSANITY. 



357 



the mania amounted to absolute delirium, with no power of attention and 
no coherence of speech whatever. I know of no clinical form of insanity 
that would yield so large a proportion of very acute cases. Puerperal 
insanity may therefore be regarded as the most acute of all forms. 

The temperature of all cases on and after admission was taken.^ It is 
always a most instructive record to look at the column of " highest tem- 
peratures" in each case. 

Of the sixty there were thirty-four cases under ,99°, and therefore 
they cannot be said to be above the average temperature of ordinary 
health, or at all events of the average temperature of the insane. But 
twenty-six cases, or forty-three per cent, of the whole, were over this, and 
of these fourteen cases, or twenty-three per cent, of the whole, were over 
100°. No other form of insanity shows this alarming result, for a tem- 
perature of over 100° I look on with alarm in any form of mental disease. 
The most serious part of it was, as we shall see, that all the deaths oc- 
curred in the cases with a temperature over 100°. Yet to show that a 
high temperature, though alarming, is not necessarily prognostic of death, 
I find that of the five cases where it was over 103° three made excellent 
recoveries. I lately saw a case in private practice who recovered, and 
whose temperature had been over 105°. The causes of the high tem- 
perature differed in different cases. The chief causes were — (1) simple 
acute brain excitement ; (2) inflammation of the womb and surroundings, 
in some cases septic, in others simple ; (3) meningeal inflammation ; (4) 
incidental causes, such as malaria, mammary abscess, etc. 

The most common and one of the most important of all the symptoms 
present was the refusal of food — paralysis of appetite. In thirty cases, 
or one-half of them, this was present. It could not be overcome but by 
the use of the stomach-pump or nose-tube in about ten cases. In a 
puerperal case refusing food I now use forcible feeding at once if food 
cannot be given in any other way. In no other kind of mental disease 
has the doctor's instructions to the nurse to be, "give much food and 
give it often." I am quite sure that most of the puerperal cases not 
septicaemic that die at home or in asylums die from want of early feeding. 
I give stimulants, too, in larger quantities with the food than in any 
other kind of insanity. I have seen the greatest and most evident good 
results from large doses of quinine as an antipyretic. In the case to 
which I have alluded where the temperature was over 105°, every ten- 
grain dose of quinine was followed regularly by a fall of from 2° to 4° of 
temperature. 

There were many other symptoms, mental and bodily, very common 
besides a high temperature. Tenderness on pressure over the region of 
the womb was common, and whenever it is present I am in the habit of 
ordering warm water vaginal carbolized injections and warm slightly 
counter-irritating poultices over the abdomen, with sometimes blistering, 
over the pubes. Local abscesses in the ankles, fingers, wrists, and body 



From 96° to 97° in 3 cases. 


Trom 101° to 102° in 3 case 


a 970 a 9go u 10 " 


a 


102° " 103° " 4 " 


u ggo li c)go u 21 " 


(< 


103° " 10-4° " 3 " 


" 99° " 100° " 12 " 


(( 


104° " 105° " 1 " 


" 100° " 101° " 2 " 


u 


105° " 106° " 1 " 



358 PUERPERAL INSANITY. 

occurred in some cases. Muscular jactitation and subsultus occurred in 
some of the worst cases, but was not always followed by collapse. (Edema 
and albuminuria were present in two cases, and convulsions in one. Of 
the mental symptoms, one of the most important from its great frequency 
was the suicidal impulse. It was present in twenty-five cases, or forty 
per cent, of the whole. It was present in an impulsive form in many of 
the maniacal as well as some of the melancholic cases. No medical man, 
therefore, in treating a case of puerperal insanity, but should keep in 
mind that the patient may attempt suicide, and he should warn the nurses 
and attendants of this. 

The presence of hallucinations of the senses, especially of hearing, I 
was surprised to find so common. They occurred in at least one- third of 
the cases, and were very often persistent, as hallucinations of hearing are 
apt to be, after the other symptoms were passing ofi". But they did not 
indicate incurability, as is the case so often in chronic auditory halluci- 
nations of alcoholic origin. 

The patients in many cases passed from the acute stage into one of 
stupor, and in some this existed from the beginning. At one part or 
other of the case stupor was present in at least fifteen cases, or twenty- 
five per cent. It was connected, I fear, in some of them with the habit 
of masturbation, to which puerperal cases are very subject. Neither the 
stupor nor the masturbation indicates incurability. One case in which 
both were the most prominent symptoms recovered. 

The last and most important point brought out in this study of these 
sixty puerperal mental cases is the great curability of the disease. Thirty- 
three cases were discharged recovered, and seventeen were discharged 
much improved. Of the latter the prospects of complete recovery were 
very good. I actually know they did complete their recovery in twelve 
cases. That is, forty-five cases out of the sixty recovered, which amounts 
to a recovery rate of seventy-five per cent. Most of the recoveries took 
place quickly. In three months from the beginning of the attack over 
one-half of the cases were well, and in six months ninety per cent, of 
those who recovered were well. But to prevent anything like loss of 
hope, I mention that one of the melancholic cases with stupor recovered 
after the disease had existed for four years. No recoveries from mental 
disease are generally better or more satisfactory than those from puerperal 
insanity. In some cases recovery was very rapid indeed after it began. 
In the cases where stupor existed or supervened on acute insanity, the 
occurrence of menstruation seemed often to act as the exciting cause of 
recovery. I myself believe that this was mostly a coincidence, or rather 
I should put it that sanity was the mental, and menstruation the chief 
bodily symptom of the restoration of brain and body to their normal 
working. It is the proper mode of treatment, however, whenever a 
puerperal case gets strong in body and the body weight becomes normal, 
to use every means to restore menstruation if it has not returned. Warm 
baths at night, mild shower-baths in the morning, hip baths with mustard, 
aloes, and iron pills, and borax at the time menstruation is expected, are 
all useful in addition to the general tonic and fresh air treatment. Men- 
struation returning before the general strength is improved is usually a 



LACTATIONAL INSANITY. 359 

bad thing, for it is apt to be attended with increased mental excitement, 
and is apt to become menorrhagic. 

Looking at curability of the cases according to their characters of 
acuteness or mildness, and of mental exaltation or depression, I find that 
the forty-three acute cases recovered in the proportion of eighty-one per 
cent., and the seventeen mild cases in the proportion of only sixty-two 
per cent. But then it must be kept in mind that the mild cases were 
longer in being sent into the asylum, and of the total number of mild 
puerperal cases occurring, the most intractable and prolonged would be 
the only ones sent into the asylum, the rest would recover at home. Of 
the exalted and depressed cases (mania and melancholia), an almost equal 
proportion, that is seventy-five per cent., of each recovered. 

Five of the sixty cases died, four of them within a month of the onset 
of the disease, and one within two months. This is a mortality of 8.3 
per cent, of the cases. No cases are more difiicult to get post-mortem 
examinations in than puerperal cases, and they were performed in only 
three of the five cases. The cause of death in one was found to be phthisis 
pulmonalis, under which the patient had labored for long before her con- 
finement, and which as usual advanced rapidly after parturition ; in 
another it was septicsemia ; and in the third simple maniacal exhaustion, 
without symptoms of septicaemia. There is no doubt, however, that the 
chief cause of death in puerperal cases that have been properly fed is 
septicaemia. They are, in fact, cases of combined puerperal fever and 
puerperal mania, the mania having more of the character of delirium 
than of ordinary insanity. It is curious that there was no history of 
preliminary chill in the septicsemic cases. As I said, I do not like the 
temperature to run up much above 100° in puerperal cases. Of the 
fourteen cases in which this took place five died, or thirty-five per cent. 
I still less like to see muscular subsultus with a restless moving of the 
hands and twitching of the facial muscles. There may be septicaemia in 
a puerperal case with purulent peritonitis, metritis, and phlebitis, and yet 
the patient never complain of any local pain, and even on pressure there 
may be no uterine or peritoneal tenderness.^ Many of the cases with the 
worst symptoms, bodily and mental, made good recoveries. 



LACTATIONAL INSANITY. 

Nursing in women is the cause of mental disease sometimes. The 
poor are more liable to this than the rich, both being equally subject to 
puerperal insanity. This is as might be expected. If the wife of a 
laborer has had ten children and nursed them all, if she has, during 
all the years those ten pregnancies and childbirths and nursings have 
been going on, had to work hard, if she has had to struggle with poverty 
and insufiicient necessaries of life in addition to this continuous repro- 
ductive struggle and family worries, if in addition to all this she has in- 
herited a tendency to mental disease, no physiologist or physician can 

^ These statistics may be carefully compared and supplemented by Dr. J. Batty 
Tuke's statistics, obtained from an analysis of cases in this asylum, in the Edinburgh 
Medical Journal for May, 1865. 



360 LACTATIONAL INSANITY. 

wonder if she should become insane during the tenth nursing. Indeed, 
the wonder is that any organism could possibly have survived in body or 
brain such a terrible strain and output of energy in all directions. Such 
a woman often enough becomes insane during a nursing long before the 
tenth. An organic sense of duty and a stern physiological necessity 
among poor women compel them to nurse their offspring. What else 
can they do ? It is well for the offspring, but the mother often enough 
dies, or is upset in body or brain in the attempt. 

A typical case of lactational insanity is one occurring in the case of a 
poor woman who has had several children, and has nursed the last for 
several months, who has got pale and thin in the process, and become 
subject to headaches, noises in her ears, giddiness, flashes of light before 
her eyes, lassitude and nervous irritability, in fact to the usual symptoms 
of general bloodlessness and brain anaemia. She then gets depressed in 
mind, her sleep leaves her, her self-control is lost, and she becomes either 
lethargic and stupid or suicidal, with delusions that her husband and 
neighbors are against her, thereby, poor woman, merely misinterpreting 
her sensations of mental pain and distress. She had little organic strength 
for her pregnancy, still less for her delivery, and it has quite broken down 
in her nursing. To such a woman the organic delight of suckling her 
infant, for which the maternal nature craves and is satisfied by the 
process, becomes an irritation, an excitement, and an exhaustion. But 
such a typical case, if taken in time, and if nursing is stopped and rest 
is given, with good, nourishing food, malt liquors, and iron and cod-liver 
oil, and fresh air, at once begins to amend, sleeps, acquires self-control, 
ceases to imagine things that have no objective existence, puts on flesh, 
begins to employ herself, gets cheerful, and is quite well and strong in 
three months, her blood containing many more blood corpuscles than it 
had when treatment was begun, and the renourished brain resuming all 
its normal functions in a normal way. But cases of lactational insanity 
vary greatly in form, degree of mental disturbance, and duration of attack. 
It must be admitted that they do not follow one type. They are nearly 
all melancholic at some period of the attack. They nearly all suffer from 
premonitory neuroses of sensation in the shape of headaches, lassitude, 
neuralgia, feelings of sinking at pit of stomach, or some of the other 
signs of anaemia and ill-nourishment. They are all very curable if put 
under proper treatment in proper time. 

The following case is an almost typical one, except that the first part 
of the asylum stage of it was more acute than usual : K. J., set. 40, the 
wife of a plumber, who earned when in full work twenty-eight shillings 
a week, has had seven children in sixteen years, and nursed each about 
fifteen months. There is no known heredity to insanity. She nursed 
the last child for twelve months, and of course had to do her familv 
duties meanwhile. Her first symptoms were great depression and want 
of energy. She would sit for hours doing nothing, saying nothing, and 
taking no notice of anything. Her brain seemed to have been exhausted 
in its power to energize mentally. Then she began to be restless and 
sleepless, and her head felt sore and queer. Soon she became delusional 
— fancying she saw friends in the street who were in the colonies. She 
was sent at first to the Royal Infirmary here, but proving unmanageable 



LACTATIONAL INSANITY. 361 

there, she was at last sent here. On admission she was markedly de- 
pressed, and the mental working of her brain was enfeebled in such a 
way that she would begin a sentence in answer to a question, and would 
stop in the middle, her volitional power having run short apparently. 
She rambled in speech and mistook the identity of persons round her. 
She had the delusion that she was to be burned at the stake. She was 
thin, pale, muscularly feeble, lacking in energy, with blunted sensibility. 
Her special senses were blunted, pulse small and weak, temperature 98.8°. 
After admission she was sleepless, restless, and acutely excited for a week. 
Then she became more quiet, with short intervals of almost sanity, but 
with impulsive action. Sitting quietly sewing in a room with others, 
she would suddenly drop on her knees and pray aloud. Was put on 
extra diet, with porter and quinine and iron. She ahvays got worse and 
more delusional in the evening, this fact probably indicating that by that 
time her brain power was getting exhausted. But she steadily picked up 
in flesh and strength, mental and bodily, and in ten months was discharged 
almost recovered, having gained twenty -four pounds in weight, and looking 
fresh and healthy. What will happen if she has more children, and nurses 
each of them fifteen months, can easily be conjectured. 

The treatment of lactational insanity is simple and physiological. Stop 
the nursing, give nourishment in abundance with some malt liquor, change 
the scene, free the patient from family cares for a time, give quinine, iron, 
cod-liver oil, and tonics generally. The suicidal tendency must be thought 
of and guarded against if present, as it is in a very large proportion of the 
cajes. 

A survey of my nine years' clinical experience in the Royal Edinburgh 
Asylum, 1874-1882, in regard to lactational insanity is instructive. We. 
have had altogether fifty-two cases that I classified as lactational. But 
some of these were old cases of the disease transferred from other asylums, 
or readmitted, and those I shall take no notice of. Their study would 
lead to no good clinical results, and would merely tend to confusion. 
Forty of the cases were admitted laboring under recent lactational in- 
sanity, and of these only I shall speak. As classified on admission, 
twenty-one of these were cases of mania and nineteen of them of melan- 
cholia. Only about half of these twenty-one cases of mania had mental 
exaltation as their predominant feature throughout their whole course, 
the others beginning with marked melancholic symptoms or ending with 
them. But the fact that half the cases were maniacal during their most 
acute period shows that the insanity of lactation is by no means exclu- 
sively a melancholic form of mental disease. It shows that bodily and 
nervous exhaustion and malnutrition, though their first mental symptoms 
may be mental depression, yet tend in a large number of cases towards 
morbid mental exaltation in the long run, mania being in fact another 
and a further stage of the convolutional brain disturbance. When 
classified according to the acuteness or mildness of their symptoms, in- 
dependently of psychical exaltation or depression, I find there were twenty- 
two acute cases and eighteen mild ones, the majority (eighteen) of the 
acute cases being maniacal, and a majority (thirteen) of the mild cases 
being melancholic. 

As regards the months of nursing in which the disease occurred, my 



362 



LACTATIONAL INSANITY. 



records do not state this point in seventeen, but of the remaining no less 
than ten occurred within the first three months, seven in the next three, 
four in the next three, and only two in the last three months. I confess 
I was surprised at this. It is a difi'erent result from that arrived at by 
Dr. Batty Tuke from an examination into the statistics of fifty-four cases 
of the insanity of lactation that had been in this asylum previous to May, 
1865. Only two of his cases occurred within the third month, and only 
eight within the first six months of nursing, while twenty-one cases, or 
fifty-one per cent, of those in whom the period was recorded, occurred 
after the ninth month of nursing, my percentage for the same period 
being nine. Such a diversity of results is enough to make one despair of 
the value of looking at clinical facts in a statistical form. My statistics 
distinctly point to the causation of this form of mental disease being largely 
due to the disturbance of the puerperal period aggravated by the reflex 
excitation of the brain through the physiological act of suckling the 
infants. Dr. Tuke's statistics clearly point to a preponderating causation 
by the exhaustion of mere long-continued nursing. Both causes operate, 
I have no doubt, but why they should have operated so differently in the 
cases in the same asylum at difierent periods I am unable to explain. 
My records were so deficient in regard to which nursing the disease oc- 
curred in as to be worthless. They merely show that lactational insanity 
may occur after the first child or the seventh. The suicidal impulse is 
common, seventeen of the forty having had it in greater or less intensity. 
The temperature shows a very marked difi'erence from the puerperal form 
of insanity.^ A glance at the highest temperature shows that only about 
one-third of the cases (thirteen) were over the normal standard, and of 
these, the great majority (eight) were only between 99° and 100°. Three 
were between 100° and 101°, leaving only two that were over that, in one 
of whom it was caused by an inflamed breast. The temperature record 
shows clearly the milder type of lactational insanity as compared with 
the puerperal form. The thermometer, though the readings seldom 
reach very high in uncomplicated mental disease, I look on as being 
simply invaluable as showing the intensity of the brain action. Its 
readings upwards, from normal to 102° or 103°, are usually in an exact 
ratio to the intensity of the mental disease. Only, it must be re- 
membered, that half a degree in the estimation of the intensity of brain 
overaction is equivalent to two degrees in the measurement of febrile 
disturbance. I attach especial importance to the readings of the ther- 
mometer in all acute mental diseases, and have used it in every case 
under my care in the Carlisle and Eoyal Edinburgh Asylums for the past 
sixteen years. 

Heredity to insanity was known to be present in fifteen of the cases ; 
but then in twelve of the forty no reliable information on this point could 
be got. And as proximate causes, mental and moral disturbances oc- 
curred in nine of the cases. 

Let us look now at the results of treatment, that most interesting of 



From 



98^ 



to 97° in 1 case. 


From 100° to 101° in 3 cases 


" 98° " 6 " 


" 101° " 102° " " 


n ggo <( 20 " 


" 102° " 103° " 1 " 


" 100° " 8 " 


" 103° '' 104° " 1 " 



THE INSANITY OF PREGNANCY. 363 

all questions to the physician, and still more so to the relatives of the 
patients. Thirty-one of the forty cases recovered, and three more were 
removed from the asylum uncured but improving. This is seventy-seven 
and a half per cent, of actual recoveries, and a still higher figure of po- 
tential restorations to mental health. The lactational cases recovered in 
slightly larger numbers, therefore, than the puerperal cases, and only 
one case of the forty died. I find that the maniacal and the melancholic, 
the acute and the mild cases recovered in somewhat equal proportions.^ 
The six who did not get better, but are still under treatment, were three 
of those patients who had repeated attacks of insanity before, the other 
three looking phthisical. The lactational cases did not recover as soon 
as the puerperal.^ Only sixteen recovered within three months, but 
twenty-five, or sixty-two per cent, of all the cases, and eighty per cent, 
of the recoveries, recovered within six months, and all of them within 
eighteen months. And they made good and lasting recoveries, few of 
them relapsing. Recovery in all the patients was accompanied by a 
great increase in body weight, in strength, in appetite, and in fatness. 
In some menstruation continued during the disease, and in its earlier 
stages acted as an excitant and exhauster of strength. It was often 
menorrhagic in such cases. The function when absent usually returned 
of itself without any special treatment as the nutrition improved. 

One instructive fact I came across in relation to this disease. Out of 
one huijdred and sixty-six admissions of ladies to our higher class de- 
partments there were only two lactational cases, while there were among 
them the usual proportion of puerperal cases. Out of 1383 pauper and 
poorer private female patients, there were thirty-eight lactational cases. 
In short, the puerperal cases were sent for hospital treatment in as great 
a proportion among the rich as the poor, while the lactational cases were 
only sent in half that proportion. This points clearly to the greater 
mildness of type of the latter, and the possibility of treating it at home, 
if not to the greater infrequency of the disease among the well-fed classes, 
who have nurses to attend their children and doctors to tell them when 
to stop nursing in time. Probably the custom among the poor of nursing 
each child a long time in order to delay the conception of the next has 
something to do with the greater prevalence of this form of mental disease 
among them. 

THE INSANITY OF PEEGNANCY. 

Few women carry a child without being influenced mentally thereby 
in some way or other. The psychology of pregnancy has yet to be 
written in a scientific way. There are innumerable facts on record, but 

* Of the twenty-one cases of mania fifteen recovered ; of the nineteen cases of niehin- 
cholia sixteen recovered ; of the twenty-two acute cases fifteen recovered ; and of the 
eighteen mild cases sixteen recovered. 



Within 1 month 6 


cases recovered. 


Within 


7 


nonths ] 


L case 


recovered 


" 2 




6 




u 


8 


(1 


I 


<i 


" 3 




4 




(( 


9 


u 


2 


<( 


u 4 




2 




ll 


11 


ii 


L 


(( 


" 6 




6 




(( 


18 


(I 




(( 


" 6 




1 















364 THE INSANITY OF PREGNANCY. 

they are scattered and undigested. Without going into the domain of 
mental disease in any technical sense, we find examples of partial mental 
exaltation, mental depression, mental enfeeblement, mental paralysis, 
and mental perversion. No doubt the alterations are chiefly in the 
affective faculties, but the reasoning power, the moral sense, the voli- 
tional power, the imagination, and even the memory, are often enough 
affected in pregnant women. As a part of the nervous disturbance the 
bodily appetites become changed, the physiological functions altered, and 
the nutrition of organs profoundly affected. In this state many women 
have endless caprices, unfounded dislikes and likings, cravings for foods 
and drinks never before desired, unnatural desires for indigestible things, 
causeless weeping and laughing, stealing and lying, morbid thirst and 
hunger, an activity of digestion never before known, pigmentation of the 
skin, alteration of the expression of the face, of the tones of the voice, 
and of the power of muscular coordination. It is scarcely surprising 
that every function of the great central nervous system should be thus 
affected in many cases, for, physiologically, pregnancy means a dynamical 
change for the time being in the direction of some of the great currents 
of energy, and a change, amongst others, in the quality of the blood. 
Psychologically it is the fulfilling of the second strongest organic necessity 
of life, to reproduce the species. All the changes, mental and bodily, that 
I have referred to, and far more than these, should be taken into account 
in studying the question of how pregnancy produces those great psychical 
disturbances that we call insanity in brains predisposed thereto. A vast 
number of women are mentally unsound during pregnancy, if judged by 
an ideal standand of volitional power, while very few indeed pass the 
conventional line that divides sanity from insanity. Nature seems to 
care for pregnant women physiologically in all directions, and does so in 
the case of the mental functions of the brain convolutions. Those may 
be, and are often, affected in pregnancy, but are seldom quite upset. It 
is a very rare foim as an insanity, as we shall see from the statistics. 
In fact, there is no period in the life of a woman after the age of twenty- 
five when she is less liable to actual insanity than during her pregnancies. 
But there is a type of case exactly the contrary of this rule, where a 
woman cannot become pregnant without becoming insane. I have such 
a patient now, who has been five times pregnant and five times insane, 
each time during pregnancy. This no doubt is the clearest indication 
nature could give that such a person should never become pregnant. I 
had one patient, K. L., who had six different attacks of insanity — two 
of pregnancy, two of puerperal, and two of lactation — and she made 
perfect recoveries from them all, though in each she was most deter- 
minedly suicidal and homicidal, strangling and killing her first child, 
and attempting at least six different times to take away her own life. 
Yet for the last seven years she has kept quite well, and done her work 
at home. She had one or two other children without being affected in 
mind more than by a little depression. 

The typical mental disturbance of pregnancy of the mild kind not re- 
quiring asylum treatment, and often not incapacitating a woman from 
doing her duties, consists of a mental depression, or mental apathy not 
amounting to stupor, with a loss of interest in things, a loss of conscious 



THE INSANITY OF PREGNANCY. 365 

affection for husband and sometimes for children, a slight weariness of 
life, a fear of something going to happen, and a general loss of courage 
and a disinclination for social intercourse. These symptoms do not 
usually come before the third month of pregnancy, and much more fre- 
quently they do not come on till after the sixth month. Sometimes they 
only last for a part of the period of pregnancy and then pass off. More 
usually they do not disappear till after delivery. They either do so then 
or become aggravated into a more acute, puerperal psychosis. There is 
another distinct type of case where during the first pregnancy insanity 
comes on, becomes acute, and ends in dementia soon. This is no doubt 
one of nature's ways of ending a bad stock ; just as I look on the in- 
sanity of adolescence to be, and on sterility to be in some cases, and on 
sexual antipathy to be, and on absence of the social instincts. There are 
psychological bachelors and old maids, born so, whom no social cultiva- 
tion or opportunity can make otherwise, and these will be found to occur 
usually in families with a heredity to insanity. 

This case presents the most common type that family doctors have to 
do with : K. M., a married woman, aet. 34, with an insane heredity, 
who had borne five children comfortably, came to me saying she was dull 
and miserable, and could not do her work nor take an interest in any- 
thing. It seemed as if she did not care for her husband, nor to do her 
household duties, and she said she was afraid of herself, meaning that she 
might commit suicide. She was stout, strong, and well-nourished, and 
looked the picture of good health. ' She slept well, ate well, and all her 
bodily functions were normal. She was in the sixth month of pregnancy, 
and the mental change had come on a month before. I advised that she 
should have a female friend with her, and should go on doing her work, 
should walk much in the fresh air, and wait patiently for her confine- 
ment. After the eighth month she felt much better, and after confine- 
ment every trace of her mental depression left her. 

The following was a very acute case of the insanity of pregnancy : 
K. N., 9et. 32, pregnant of an illegitimate child, became at the sixth 
month dull and apathetic, then within a month incoherent, talkative, and 
almost delirious. She would moan at times as if in pain ; would say, 
poor soul, "I am in a fearful state ; never was in such a state as this." 
She had hallucinations of sight, seeing elephants all of a green color 
before her. She was very weak on admission, could not walk well with- 
out assistance, her tongue and mouth tended to be dry, she had pain in 
her abdomen, her ankles were swollen, her pulse was 136 and weak, and 
her temperature 100.4°. She continued restless, depressed, excited, and 
sleepless, and eight days after admission was delivered of a healthy male 
child. Her mental state improved much thereafter for a week, when she 
had a relapse. In fact, the puerperal state caused an access of puerperal 
insanity, but in four weeks after the birth of the child the excitement 
had passed off, the delusions only remaining. In another week the de- 
lusions, too, had left her, and in two months she was discharged strong 
in body and well in mind. 

The next is a more characteristic case, K. 0., set, 30, a married 
woman with a hereditary history of insanity, and pregnant with her first 
child, became insane six weeks before its birth ; a fear came over her 



366 THE INSANITY OF PKEGNANCY. 

first, and she said, "I must die, I must die." An inflammation in one 
lung had reduced her strength, and she had heen sleepless for two weeks, 
soporifics having no effect. She was suicidal, and tried to jump out of a 
window. Her friends properly kept her at home, nursing and looking 
after her as best they could till the child was born. She then got much 
worse mentally, and remained maniacal for two months. Then she 
became apathetic, confused, and childish, with occasional impulsive 
spurts of maniacal excitement. This state lasted for a month, then she 
began to improve, and was well in six weeks, her attack having lasted 
altogether five months. The bromides and iron were used largely in the 
acute stage of her disease. Strychnine in the apathetic stage, and extra 
food and fresh air and good nursing throughout. 

The cases of the insanity of pregnancy of such an acute type as to need 
asylum treatment are rare and by no means of a uniform type. I have 
had only fifteen such in the past nine years sent to the Royal Edinburgh 
Asylum ; nine of these were maniacal and six melancholic ; nine of an 
acute type, and six were mild in their symptoms ; seven of them were 
suicidal, some being desperately so. This is an enormous proportion of 
suicidal cases for any kind of insanity. In half of those with a history 
there was heredity to insanity, mostly strong and direct heredity. 

Of the fifteen cases only nine recovered, or sixty per cent, of the 
whole, this form of mental disease in its w^orse forms being thus more 
incurable than the insanities of childbed or nursinoj. The time of re- 
covery in relationship to confinement was various. In only two cases of 
the nine who recovered was the termination of pregnancy attended with 
speedy and marked mental recovery. In four cases confinement dis- 
tinctly aggravated the previously existing mental disease. In three of 
these, in fact, the symptoms had not been so bad before confinement as 
to need asylum treatment at all. The puerperal state seemed to bring 
the insanity of pregnancy to a climax in those cases. In three cases of 
the nine who recovered they got better, and were discharged from the 
asylum recovered before they were confined. The whole nine had re- 
covered in six months. Three cases were transferred to other asylums 
within four months after admission here in an improved condition, and 
of these one might possibly have got better ultimately, and one was taken 
home before recovery and did get quite well. This would bring up the 
recovery rate to seventy-three per cent. Two died, one of uraemic 
poisoning (this probably having been the real cause of her insanity) in 
seven days after admission, and another of general tuberculosis in ten 
months. 

Women are more liable to become insane during the first than subse- 
quent pregnancies ; for seven of the fifteen cases were first pregnancies ; 
and the fact that five of the fifteen were illegitimate children, shows that 
moral causes largely bring on the disease. 

The coming on of the disease was gradual in most of the cases, and it 
began in all but two with depression of mind or apathy and stupor. 
The affection tow^ards their husbands became perverted in nearly all the 
married cases. The psychology of the affection between husband and 
wife, and the way it is influenced by sexual intercourse, by pregnancies, 
by the children or the absence of children, by neurotic constitution of 



THE INSANITY OF PREGNANCY. 367 

brain, by the climacteric, and by old age, has yet to be written from the 
physiological point of view. Many strange chapters on this subject could 
family doctors write. I have not had a single case of the insanity of preg- 
nancy in a rich patient sent here. This is natural and proper, for if any 
kind of mental disease should be kept out of asylums without sacrificing 
life or recovery, it is this. It would be a terrible fate, as things go in 
this world, to be born in a lunatic asylum, in addition to being the child 
of an insane mother. The asylum cases cannot be taken as the real type 
of the insanity of pregnancy. 

The treatment of the insanity of pregnancy is in no way special. The 
women are not usually run down. The temperature in only four of my 
cases (one being the ursemic case) was above 99°. Fresh air, exercise, 
watching, nursing, employment, cheerful society, change, freedom from 
too much work and worry, and suitable food, are about all we can do. 
Slight sedatives may be required as placebos^ but in as small doses and 
as seldom as possible. The blood of an insane mother needs not to be 
mixed with morphia or chloral to make it bad for her unborn progeny. 
The tendency to suicide must be specially kept in mind. One of my 
cases had a secondary syphilitic eruption and needed treatment for that, 
and in two more I suspected syphilis, both children being prematurely 
born dead. 

Together the insanities of childbed, nursing, and pregnancy have con- 
stituted over nine per cent, of all the female cases in the Royal Edinburgh 
Asylum for the past nine years (1874-1882), there being 141 cases out 
of 1549 admissions (including readmissions). There was 5 per cent, of 
the puerperal form, 4 per cent, of the lactational, and 1 per cent, of the 
insanity of pregnancy. As we admit all classes of society, this may be 
taken to represent the real effect of childbearing in the production of in- 
sanity, at least in this part of the country. In Cumberland and West- 
moreland for the ten years (1863-1872), during which I was in charge 
of the Carlisle Asylum (for the poorer classes only), there were 75 cases 
out of 431 female patients in all, or 17.4 per cent. This enormous dif- 
ference of nearly twice the proportion is made up entirely of the excess 
of puerperal cases, there having been 51 of these, or 11.8 per cent, of 
the whole of the female insane of those two counties. That is more than 
twice the Edinburgh proportion. Such great differences in the local dis- 
tribution of the different forms of insanity is an interesting problem in 
medico-psychology that needs to be worked out as to its causes. 



LECTURE XVI. 

THE INSANITIES OF PUBERTY AND ADOLESCENCE. 

When one considers the enormous differences in the physiological life 
and prevailing brain activity of the same human being at the different 
periods of life, it does not seem wonderful that each period has its own 
type of psychological disturbances, just as it has its special kinds of ordi- 
nary disease. Indeed, it would be very wonderful if the brain of a child, 
whose chief characteristics are active development, intense inquisitive- 
ness in all directions, great sensitiveness to impressions, which succeed 
each other rapidly, and, whether they are painful or pleasurable, leave 
only slight lasting traces, if this organ manifested quite the same dis- 
turbances when its mental functions become deranged as the brain of an 
old man, whose chief characteristics are retrogression in all its activities, 
and insensitiveness to ordinary impressions. The essential qualities of 
the two organs are in many respects different ; their receptive, dynamical, 
and trophic activities are quite dissimilar. Then what a change in the 
mental activity of the brain does the period of puberty cause ! Looking 
at the matter from the combined point of view of physiologists and psy- 
chologists, we must connect the new development of the affective faculties, 
the new ideas, the new interests in life, the new desires and organic 
cravings, the new delight in a certain sort of poetry and romance, with a 
new evolution of function in certain parts of the brain that had lain 
dormant before. This awakening into intense activity of such vast tracts 
of encephalic tissue, though provided for in the evolution of the organ, 
does not take place without risk of disturbance to its mental functions, 
especially where there is an inherited predisposition in that direction. 
And if this predisposition is thus developed into actual derangement of 
function, it happens, as might have been surely predicted a priori, that 
the type of derangement is much influenced by the great function of the 
reproduction of the species then arising de novo. To form a right con- 
ception of the kinds of mental disease that occur at the various important 
periods of life it is essential that we consider them in connection with the 
normal changes that take place in the organism at these periods, with 
the normal modifications in the mental energy at those periods, and 
with the changes that take place in the brain texture and mode of action, 
so far as we know them. In short, we must take a physiological view of 
mental disease. 

The Period of Puberty or Pubescence. — The period of puberty is 
the next great physiological era in the life of man after that of birth. 
Before that occurs the whole trophic and mental energy has been 
occupied in acquisition alone. There has been no production. Before 
that time there has been a general psychical likeness between individuals 



INSANITIES OF PUBEETY AND ADOLESCENCE. 369 

of the same and of opposite sexes which then rapidly disappears. 
Individualities of all kinds spring up far more decidedly at that time in 
those of the same sex ; while, dividing the sexes at this time, there arise 
most striking psychical differences that far exceed the bodily contrasts. 
Up to that time the mental development of each sex has been very much 
in the same direction ; after puberty that development takes place in the 
man far more in the direction of energizing and cognition, in the woman 
in the direction of emotion and the protective instincts. But these 
changes do not ordinarily take place all at once in the human species, 
any more than a full capacity for reproduction takes place in either sex 
immediately the testes assume their function, or menstruation and 
ovulation are set up. It takes several years for the full development of 
the size and form of the body that is normal and typical for each sex, and 
it takes still longer for the complete evolution of the masculine and 
feminine psychical characteristics. It is not at the time of the first 
appearance of the reproductive function chiefly that there is peril to the 
healthy mental balance, but those after-years of gradual coming to 
maturity are often full of danger to the mental health of both sexes. It 
cannot be otherwise. The hereditary influences and tendencies that all 
the former generations have transmitted to a man come then most fully 
into play. And when ,we consider for a moment that it is not only his 
father's and his mother's own inherited tendencies that may come to him, 
but their acquired peculiarities as well, and not only so, but the inherited 
and acquired peculiarities of his four grandparents and his eight great- 
grandparents, not to go any further back, how great a risk does every man 
and woman run of suffering for the sins of their fathers ! Maudsley 
speaks of a man's yielding to the tyranny of his organization. We 
might go further, and say he may fall a victim to his grandfather's 
excesses. Most fortunately for the race, there are other influences 
obviating such effects of heredity. One is that the tendency towards 
reproducing the normal and healthy type is generally stronger than 
towards the abnormal. If the conditions of life are favorable, mere ten- 
dencies never develop, and potentialities never become actualities. The 
other is, that when the tendency to abnormality is strong the victim of it 
often dies before the age of reproduction, or he is incapable of procreation. 
Now, the insanity of puberty is always a strongly hereditary insanity ; 
it, in fact, never occurs except where there is a family tendency towards 
mental defect or towards some other of the neuroses. Its immediate 
cause may be some irregularity in the coming on of the reproductive or 
menstrual function ; its real and predisposing cause is heredity, having 
for its object this higher physiological law, that the reproduction of the 
species is stopped vfhen the inherited tendency to brain disease acquires a 
certain strength in any individual. 

I cannot help here adverting to the absurd and unphysiological theories 
of education which are sometimes taught, and which we as medical men 
should combat with all our might. The old practice of attending to the 
acquisitive and mnemonic faculties of brain alone in education is now 
fortunately giving way. The theory of any education worth the name 
should be to bring the whole organism to such perfection as it is capable 
of, and to train the brain power in accordance with its capacity, most 

24 



370 INSANITIES OF PUBERTY AND ADOLESCENCE. 

carefully avoiding any overstraining of weak points — and an apparently 
strong point in the brain capacity of a young child may in reality be its 
weakest point in after-life. I have known a child with an extraordinary 
memory at eight, who at fifteen could scarcely remember anything at all. 
Then as the age of puberty approaches, one would imagine, to hear some 
scholastic doctrinaires talk, that it was the right thing to set ourselves by 
every means to assimilate the mental faculties and acquireiiients of the 
two sexes, to fight against nature's laws as hard as possible, and to turn 
out psychically hermaphrodite specimens of humanity by making our 
young men and women alike in all respects, to make our girls pundits and 
doctors, and our young men mere examination-passers. If there is any- 
thing which a careful study of the higher laws of physiology in regard to 
brain development and heredity is fitted to teach us, it is this, that the 
forcing-house treatment of the intellectual and receptive parts of the 
brain, if it is carried to such an extent as to stunt the trophic centres 
and the centres of organic appetite and muscular motion, is an unmixed 
evil to the individual, and still more so to the race. There is no time or 
place of organic repentance provided by nature for the sins of the school- 
master. 

Some educationalists go on the theory that there is an unlimited 
capacity in every individual brain for education to any extent, in any 
direction you like, and that after you have strained the power of the 
mental medium to its utmost, there is plenty of energy left for growth, 
nutrition, and reproduction. Nothing is more certain than that every 
brain has at starting just a certain potentiality of education in any one 
direction and of power generally, and that it is far better not to exhaust 
that potentiality, and that if too great calls are made in any one direction 
it will withdraw energy from some other portions of the organ. These 
persons forget that the brain, though it has multiform functions, yet has 
a solidarity and interdependence through which no portion of it can 
be injured or exhausted without in some way interfering with the func- 
tions of the other portions. Even the very anatomical and histological 
composition of the organ might teach us this. The way in which 
its several elements that minister to mental functions, motion, sensation, 
regulation of temperature, and nutrition, are mixed up in the cortex, and 
even in the centres lower down, have as yet defied our anatomical 
and physiological investigations even to distinguish the one clearly from 
the other. To expect that any one man could have the biceps of a 
blacksmith, the reasoning powers of a Darwin, the poetic feeling of 
a Tennyson, the procreative power of a Solomon, and the longevity of a 
Parr, is simply to expect a physiological miracle. As Mr. G. H. Lewis^ 
says: "Owing to the action and reaction of blood and plasmode, 
of tissues on tissues, and organs on organs, and their mutual limitations, 
the growth of each organism has a limit, and the growth of each organ 
has a limit. Beyond this limit no extra supply of food will increase the 
size of the organism, no increase of activity will increase the (power of 
the) organ — 'Man cannot add a cubit to his stature.' The blacksmith's 
arm will not grow larger by twenty years of daily exercise after it has 

1 Physical Basis of Mind, p. 184. 



INSANITIES OF PUBERTY AND ADOLESCENCE. 371 

once attained a certain size." The possible extent of development of 
every brain and of every function in any one brain is just as much con- 
fined by limitations as the size of the blacksmith's arm, and physiology 
teaches us that no organ or function should be worked even up to its full 
limit of power. No prudent engineer sets his safety-valve just at the 
point above which the boiler will burst, and no good architect puts weight 
on his beam just up to the calculation above which it will break. Nature 
generally provides infinitely more reserve power than, the most cautious 
engineer or architect. She scatters, for instance, seeds in millions for 
hundreds to grow, and she is prodigal of material and strength in the 
heart and arteries beyond what is needed to force the blood-current 
along ; therefore we have no reason to think that any function of the 
brain should be strained up to its full capacity except on extreme 
emergencies, or that any of the receptive or sensory brain-tissues should 
be stored choke-full of impressions for the purpose of being frequently 
called up again as representations. Especially do these principles apply 
if we have transmitted weaknesses in any function or part of the organ ; 
and what child is born in a civilized country without inherited brain 
weaknesses of some sort or in some degree ? 

These principles also apply, I believe, most strongly to the whole 
reproductive functions of the body and its centres in the brain, both in 
the male and the female. Especially are they applicable in the case of 
the female organism, on which the chief strain of reproducing the species 
rests. The risks to the mental functions of the brain from the exhaust- 
ing calls of menstruation, maternity, and lactation, from the nervous 
reflex influences of ovulation, conception, and parturition, are ruinous if 
there is the slightest original predisposition to derangement, and the 
normally profound influences on all the brain functions of the great eras 
of puberty and the climacteric period are too apt, in these circumstances, 
to upset the brain stability. Beyond all doubt, boarding-school education 
has not as yet been conducted on physiological principles, and is respon- 
sible for much nervous and mental derangement, as well as for difficult 
maternity ; but if the education of civilized young women should become 
what some educationalists would wish to make it, all the brain energy 
would be used up in cramming a knowledge of the sciences, and there 
would be none left at all for trophic and reproductive purposes. In fact, 
for the continuance of the race there would be needed an incursion into 
lands where educational theories were unknown, and where another rape 
of the Sabines was possible. American physicians tell us that there are 
some schools in Boston that turn out young ladies so highly educated 
that every particle of their spare fat is consumed by the brain-cells that 
subserve the functions of cognition and memory. If these young women 
do marry, they seldom have more than one or two children, and only 
puny creatures at that, whom they cannot nurse, and who either die in 
youth or grow up to be feeble-minded folks. Their mothers had not only 
used up for another purpose their own reproductive energy, but also most 
of that which they should have transmitted to their children ; nature, no 
doubt, making provision for the transmission of the unused-up energy of 
one generation on to the next, on the principle of the conservation 
of force. As physicians — the priests of the body and the guardiiuis of 



372 INSANITIES OF PUBERTY AND ADOLESCENCE. 

the physical and mental qualities of the race — we are, beyond all doubt, 
bound to oppose strenuously any and every kind and mode of education 
that in any way lessen the capability of woman for healthy maternity, 
and the reproduction of future generations strong mentally and physically. 
Why should we spoil a good mother by making an ordinary grammarian ? 
The relation of the psychical and emotional development to the generative 
function is full of interest and importance to us as physiologists, and few 
men have been long in practice before such questions obtrude themselves 
as very practical ones indeed. The first hysterical girl a man has to treat 
in a good family, where he does not want to lose the case or the family 
practice, may test severely his knowledge of the reflex relationship of the 
uterus with the sensory, motor, and mental functions of the brain. We 
must, as much as we can, study the conditions and relations of phenomena 
of all kinds. It is a mere cloak for ignorance, and an excuse for not 
thinking, to call certain abnormal phenomena "hysterical," and imagine 
that explains them. It does not require much consideration to see that 
at the period of puberty in both sexes, but especially in the female, the 
direct connection of certain physiological functions and processes with 
certain mental facts influences the whole life of the individual. If that 
connection is in any way abnormal, we have great strains on the mental 
functions of the brain, and sometimes actual derangement. Our high 
civilization and refinement, no doubt, add immensely to the risks by 
increasing the strain. The psychological analysis of what female 
modesty is, by a physiologist, reveals the transformation and apotheosis in 
the higher regions of the brain of reflex impressions from the reproductive 
organs into a high moral quality, not only beautiful, but absolutely 
essential to social life. How can a physician understand the true import 
of the obtrusive and grotesque modesty of a hysterical patient except he 
takes this into account ? The intense and complete outward repression 
and inhibition of certain physiological cravings required by our morals 
and our civilization cause, no doubt, a dangerous strain on the brain 
functions, and a reaction in other directions, where there are hereditary 
neurotic weaknesses. 

Puberty is the first really dangerous period in the life of both sexes as 
regards the occurrence of insanity ; but it is not nearly so dangerous as 
the period of adolescence, a few years afterwards, when the body, as well 
as the functions of reproduction, have more fully developed. The nutri- 
tive energy of the brain is so great in youth, its recuperative power so 
vigorous, and its capacity for rest in sleep so powerful, that its mental 
functions are not often upset at this period. To bring out this fact 
statistics are useful. In Scotland, at the present time, nearly one-half 
the population are under the age of 20 ; while in the Royal Edinburgh 
Asylum we have, out of a total of 730 patients, only ten under that age. 
The contrast between 50 per cent, and 1.5 per cent, in the sane and 
insane populations is a very marked one. But, to show how different is 
the state of matters in the older periods of life, let us compare the num- 
ber of persons over 60 in Scotland and in the asylum. In the general 
population there are just about 8 per cent, over that age, while in the 
asylum, out of the 730, there are no less than 126, or 17 per cent. Or, 
to bring out the facts difierently, it is found that the number of people 



INSANITIES OF PUBERTY AND ADOLESCENCE. 373 

SO insane as to require to be sent to asylums is about one in 600 of the 
population. Now, at this rate, our 730 inmates represent an ordinary 
population of 438,000. One-half of these, or 219,000 persons, are 20 
years of age or under, and they have only supplied ten of our lunatics, 
insanity occurring in them at the rate of only one in 21,900, while the 
remaining half of the general population, that over 20, had produced 720 
lunatics, or one in 304, that is, in seventy times the proportion of those 
under 20 years of age. After the age of 20 there is no such enormous 
disproportion in the production of lunacy. It is undoubtedly most fre- 
quent between the ages of 35 and 55. Speaking generally, therefore, 
insanity in its worst forms is not a disease of youth or puberty, but of 
middle and advanced life. Slight attacks of nervous and mental de- 
rangement, however, that do not require asylum treatment, are by no 
means uncommon in those predisposed to the neuroses at the earlier 
ages, especially in the female sex ; and if the general health and strength 
and nutrition are poor, puberty is liable to cause neurotic symptoms in 
those cases. Such symptoms, if there is an inherited predisposition to 
insanity, should by no means be despised. They may develop into 
actual insanity at a later period. For the production of decided insanity 
requiring asylum treatment at the age of puberty, we must, as I said, 
have a strong neurotic predisposition, as well as the advent of the repro- 
ductive era and the changes it brings along with it. I have scarcely ever 
met with a case without this. Other affections of the nervous centres 
are very apt to appear at this period of life, notably the two great 
derangements of the motor centres, epilepsy and chorea. The motor 
centres are, no doubt, more unstable and easily upset in their working in 
youth than either the mental, sensory, or trophic centres. Infantile 
convulsions are the nervous disease of infancy. I believe that if there 
is a hereditary predisposition to any neurosis whatever in infancy, it most 
frequently shows itself in a special tendency to infantile convulsions 
during dentition. We find that the majority of cases of epilepsy and 
chorea in the female begin at the period of puberty. The insanity of 
puberty in both sexes is characterized especially by motor restlessness. 
Such patients never sit down by night or day, and never cease moving. 
There is noisy and violent action, sometimes irregular movements, or, in 
the few melancholic forms and melancholic stages of the maniacal cases, 
cataleptic rigidity. The mental symptoms consist most frequently of a 
kind of incoherent delirium rather than any fixed delusional state. In 
boys, the beginning of an attack is frequently ushered in by a disturb- 
ance in the emotional condition, dislikes to parents or brothers or sisters 
expressed in a violent, open way; there is irrational dislike to, and 
avoidance of, the opposite sex. The manner of a grown-up man is 
assumed, and an offensive ''forwardness" of air and demeanor. This 
soon passes into maniacal delirium, which, however, is not apt to last long. 
It alternates with periods of sanity, and even w^itli stages of depression. 

This is one of the most characteristic cases of the early insanity of 
puberty I have met with. I have seen others presenting the same pecu- 
liar symptoms : 

K. P., aet. llj, of an active and cheerful disposition, and a bright boy 
at school. His parents were poor, and he was brought up in a poor part 



374 INSANITIES OF PUBERTY AND ADOLESCENCE. 

of the town. His mother had an attack of puerperal insanity (mania) 
after the birth of a child born before K. P., and another attack of ordi- 
nary acute delirious mania after he had been sent to the asylum, from 
both of which she recovered. He has an elder brother who, at the age 
of nineteen, had an attack of acute adolescent insanity (mania), and 
became demented, and is now in the asylum. There was no exciting 
cause of the boy's illness. He caught a feverish cold, and then became 
exalted in mind, singing continuously, clinging to his mother, saying he 
was going to heaven. This continued all day, but at night he slept 
twelve hours, and he took his food as usual. When sent to the asylum 
there was a very peculiar mixture of mental exaltation and depression 
present. He went on all the time singing joyful hymns in lively tunes, 
but in a voice as if crying. He would not answer questions or take 
any notice of anything about him, and could not be made to attend to 
anything any more than if he had been in a condition of trance. His 
whole condition was one of almost mental automatism, and as he sang he 
would rock himself, and keep time rhythmically with his hands and body. 
If anyone put their arms round him, he would cuddle up to them, and in 
a child's whining voice sing, " Tak me to ma mammy. Oh, my bonny 
mammy, my bonny mammy; come to me, mammy. Have mercy on 
me," etc., over and over again, in a rhythmical way; and if his eyes 
were shut and covered up he would go right off to sleep. The moment 
he awoke, the singing would begin. If he were much interfered with, 
he would shout and resist in a sort of unconscious way. He was poorly 
nourished and weak in body. He was sent out in the open air much, 
and was ordered a large quantity of milk and cod-liver oil emulsion. In 
about seven days the state of delirium passed off, and he got quite well 
mentally. His father took him home in three weeks, but he got into 
precisely the same state again on finding his mother insane at home and 
unable to speak to him. His mother was taken to the asylum, and he 
took the delusion that his father, too, was dead and gone. In about a 
fortnight he passed out of the delirium, and became quite cheerful and 
active. Just four weeks and two days after his second admission, he 
complained first of toothache, and then almost immediately became very 
excited, and said he could not see, sobbed, shouted, and was with diffi- 
culty restrained from throwing himself about. The symptoms were more 
those of ordinary acute mania, but with some of the former delusions, 
automatism, and facility for sleeping. This attack lasted for a few days 
only. He then remained well for exactly four months, and then had 
another attack, preceded by dilatation of the pupils and dimness of 
vision. The attack lasted for three days. He then got well again, but 
in another month to a day he got excited and emotional again. Though 
his face looked sad, and his voice was that of weeping, he never shed 
tears. This, the fifth, was the last attack he had ; after that he kept well, 
was sent home, and has now been there for more than a year. During 
the whole of the time he was in the asylum he was getting stronger and 
fatter, and was a well-nourished, cheerful boy, with no peculiarities what- 
ever, when he left. 

The chief features of this case were — (1) the suddenness of the coming 
on of the mental attacks, without external cause ; (2) the curious auto- 



INSANITIES OF PUBERTY AND ADOLESCENCE. 375 

matic delirious character of them, the mixture of exalted feeling with de- 
pression, and the impossibility of rousing his attention to anything outside 
of him ; (3) the way in which he went off to sleep when his eyes were 
closed and an arm was put round him, in both these respects resembling 
hypnotism ; (4) the repetition of the attacks in irregular monthly periods ; 
(5) his complete recovery at last. 

I look on such a case as an example of the evolution of a new function, 
that of generation, upsetting the convolutional working of a brain strongly 
predisposed by heredity to insanity. The physiological problem solving 
in the brain at this time seemed to be — Shall the organism have power 
to reproduce itself? or shall it die in its highest function (mentalization) 
in the process of the evolution of the power to reproduce ? His elder 
brother had been attacked with insanity, not at puberty, but during 
adolescence, at the age of nineteen. He had at first exhibited a good 
many cataleptic symptoms, a motor automatic condition, just as K. P. 
had many mental automatic symptoms. In each case the " higher 
centre" of volition was powerless. The brother, after being maniacal 
for about two years in periodic intervals, has sunk into dementia. In 
him nature has stopped the reproduction of the species. 

The treatment I look on as an attempt so to strengthen the vital forces 
and the nutrition of the organism, that it shall pass through the whole 
period of the evolution of the new function without undergoing the risk 
of the destruction of all the higher mental faculties. 

K. P.'s case was no doubt in the very earliest stage of puberty, and, 
indeed, in some of its mental characters partook of some of the charac- 
teristics of the delirium of childhood. 

Adolescence. — The mental disturbance characteristic of this period 
is closely allied to that which occurs at puberty. It occurs later, between 
the ages of eighteen and twenty-five, notably between twenty and twenty- 
five, when the function of reproduction is attaining its full development 
and the body is arriving at its full growth. That there is such an era in 
life physiologically is sufficiently proved by the existence in all languages 
of a word to signify the same thing as our " adolescence." I cannot hope 
to change the accepted meaning of the present nomenclature, but I would, 
if I could, distinguish between puberty and adolescence in this way — I 
should restrict puberty, as is now done when the term is used in a scien- 
tific and physiological sense, to the initial development of the function of 
reproduction, and to its first appearance as an energy of the organism ; 
while I should use adolescence to denote the whole period of twelve years 
from the first evolution up to the full perfection of the reproductive energy, 
when the bones are finally consolidated, and the full growth of the beard 
and the sexual hair takes place, and there occurs the perfect assumption 
of the manly form in the male sex, and the full development of the adipose 
tissue and the mammae gives the female form its perfect grace of contour. 

Dr. Mathews Duncan has proved statistically that in the female sex 
"the climax of initial fecundity," which may be taken as proof of full 
development, "is about the age of twenty -five years. "^ This maybe 
assumed to be the case for both sexes. 

1 Fecundity, Fertility, and Sterility, 2d ed., p. 33. 



376 INSAI^TTIES OF PUBERTY AND ADOLESCENCE. 

Looked at from a psychological point of view, it can scarcely be denied 
by anyone that the later years of adolescence are far more important 
than the first. For years after puberty boys and girls are still boys and 
girls in mind, but as a physiological fact the female sex attains its full 
bodily development first. At twenty-one the great majority of that sex 
have attained perfect physiological development, and Duncan's statistics 
show that their initial fecundity is then almost at its climax. But this 
is not so in the male sex. The growth of the beard and the form of the 
body do not reach full development in that sex on an average till the age 
of twenty -five. Mentally the difference is still more marked. The subtle 
but profound mental influences of adolescence have usually reached their 
full maturity in women three or four years before men.^ 

A careful study of human nature will soon show any observer that the 
period of adolescence in this sense is a most momentous one. The mental 
change that takes place from eighteen to twenty-five is incomparably more 
important, and I think more interesting psychologically, too, than that 
which occurs between fourteen and eighteen. The psychological change 
at puberty is, no doubt, great from childhood ; but it is inchoate and 
nascent ; it wants precision and conscious power ; its emotionalism is 
utterly spasmodic and childish ; its sentiment wants tenderness, and its 
ambitions and longings are mere castle-building in the air. 

At adolescence in the male sex life first begins to look serious, both 
from the emotional side and in action. It is then only that childish 
things are put away. For the first time is literature, in any correct 
sense, appreciated. Poetry, not even understood before, now becomes a 
passion, at least certain kinds of poetry. Not that the highest kind of 
literature is reached. No adolescent ever really appreciated, or even 
thoroughly liked, Shakespeare. That is reserved for full manhood. 
The kind of novel that is enjoyed is always a good test of the mental 
and emotional development. The boy enjoys Ballantyne and Marry*t; 
G. P. R. James begins to have a dim meaning to the youth ; at puberty 
the adolescent takes to Scott, Dickens, and Miss Austin ; while only the 
man enjoys and understands Shakespeare, George Eliot, and Thackeray. 
Go into a university and watch the demeanor of the first and fourth 
year's man, if anj^one has any doubt as to the immeasurable distance 
between puberty and adolescence. There seems to be a great gulf fixed 
between them. The fourth year's man treats his junior not as a mere 
junior, but as of a different and inferior species. He never speaks to 
him if he can help it ; he would no more room with him than he would 
with a baby in arms. Watch the two in the presence of the opposite sex. 
Their behavior is quite different. In the one case you see mere shyness, 
that breaks out into rollicking fun the moment a real acquaintance is 
formed ; in the other there is real sexual egoism, that most painful 
pleasure that consists of the half unconscious organic feeling that each 
person of one sex is an object of the most intense interest to each person 
of the opposite sex about the same age. The real events and possibilities 
of the future are refiected in vague and dreamlike emotions and longings, 
that have much bliss in them, but not a little, too, of seriousness and diffi- 

1 See Edinburgh Medical Journal, July, 1879, "The Study of Mental Diseases," 
by the author. 



INSANITIES OF PUBERTY AND ADOLESCENCE. 377 

culty. The adolescent feels instinctively that he has now entered a new 
country, the face of which he does not know, but yet that is full of possi- 
bility of good and happiness for him. He has a craving, too, for action 
of some sort — not merely the football action of the boy, but something of 
more serious import. Longfellow's youth that vaguely cried " Excelsior " 
was evidently at this stage of life. His reasoning faculty first gets some 
backbone at this period. His emotional nature acquires for the first time 
a leaning towards the other sex that quite swallows up the former emo- 
tions. It is not yet at all under his control, fixed or definite in its aims. 
His sense of the seriousness and responsibility of life may be said to 
awake then for the first time in a real sense. The first sense of right 
and wrong and of duty becomes then more active instead of passive. He 
has yearnings after the good, and is capable of an intense hatred and 
scorn of evil which he could not have experienced before. 

But it is in the female sex that the period of adolescence has attracted 
most attention, especially among those psychological students and deline- 
ators of character, the novelists of the day. As physicians, we know 
that it is only then that hysteria, migraine, and the graver functional 
and refiex neuroses arise. As men of the world, we know that the love- 
making, the flirting, the engagements to marry, and the broken hearts 
of the adolescents are not really very serious affairs. The cataclasms of 
life do not happen then. We know that no artist ever painted, or no 
sculptor ever modelled, a Venus who had not passed adolescence. A very 
fine and most interesting §tudy ofadolescence in the female sex is, in my 
opinion, to be found in the Gwendolen Harleth of George Eliot's novel 
of Daniel Deronda. This authoress was by far the most acute and 
subtle psychologist of her time, and certainly the character I have men- 
tioned is most worthy of study by all physicians who look on mind as 
being in their field of study or sphere of action. From the time when, 
at the gaming-table, Gwendolen caught Deronda's eye, and was totally 
swayed in feeling and action by the presence of a person of the other sex 
whom she had never seen before; playing, not because she liked it or 
wished to win, but because he was looking on, all through the story till 
her marriage, there is a perfect picture of female adolescence. The 
subjective egoism tending towards objective dualism, the resolute action 
from instinct, and the setting at defiance of calculation and reason, the 
want of any definite desire to marry, while all her conduct tended to 
promote proposals, the selfishness as regards her relations, even her 
mother, and the organic craving to be admired, are all true to nature. 
Witness her state of mind when Grandcourt first appeared : 

"Hence Gwendolen had been all ear to Lord Brackenshaw's mode of accounting 
for Grandcourt's non-appearance ; and when he did arrive, no consciousness was more 
awake to the fact than hers, although she steadily avoided looking towards any point 
where he was likely to be. There should be no slightest shifting of angles to betray 
that it was of any consequence to her whether the much-talked-of Mr. ]Mallinger 
Grandcourt presented himself or not. And all the while the certainty that he was 
there made a distinct thread in her consciousness." 

Again : 

" Gwendolen knew certain differences in the characters with which she was con- 
cerned as birds know climate and weather." 



378 INSANITIES OF PUBERTY AND ADOLESCENCE. 

The sentimentality of this period of life is well illustrated when Gwen- 
dolen says : 

" ' I never saw a married woman who had her own way.' ' What should you like 
to do?' said Alex, quite guilelessly, and in real anxiety. [He was an adolescent just 
entering on the period.] ' Oh, I don't know ! Go to the North Pole, or ride steeple- 
chases, or go to be a queen in the ball, like Lady Hester Stanhope," said Gwendolen 
flightly. ' You don't mean you would never be married.' 'No, I didn't say that. 
Only, when I married, I should not do as other women do.' " 

The inchoate religious sentiment, as a psychological faculty contending 
with the egoism, is thus brought out : 

" What she unwillingly recognized, and would have been glad for others to be un- 
aware of, was that liability of hers to fits of spiritual dread. . . . She was ashamed 
and frightened as at what might happen again, in remembering her tremor on sud- 
denly finding herself alone . . . Solitude in any wide scene impressed her with 
an undefined feeling of immeasurable existence aloof from her, in the midst of which 
she was helplessly incapable of asserting herself. With human ears and eyes about 
her, she had always hitherto recovered her confidence, and felt the possibility of win- 
ning empire." 

The selfishness and craving for notice are thus hit off: 

" I like to differ from everybody. I think it is stupid to agree." 
" Her thoughts never dwelt on marriage as the fulfilment of her ambition. . . . 
Her observation of matrimony had induced her to think it rather a dreary state, in 
which a woman could not do as she liked, had more children than were desirable, was 
consequently dull, and became irrevocably immersed in humdrum. Of course, mar- 
riage was social promotion. She could not look forward to a single life. . . . She 
meant to do what was pleasant to herself in a striking manner; or rather, whatever 
she could do so as to strike others with admiration, and get in that way a more ardent 
sense of living, seemed pleasant to her fancy." 

But extracts merely spoil the whole picture, which is one that is in 
perfect accord with the facts of nature, drawn by a consummate artist. 
It is one of the most perfect psychological studies with which I am 
acquainted. 

It seems like passing from the poetry of science to Dryasdust's details, 
to descend from George Eliot's word-pictures to the details of physio- 
logical fact and speculation that underlie all this charming maiden's 
mental constitution. I think most medical men of extensive observation 
would agree with me, that the incompleteness of those mental tokens of 
merely developing womanhood and manhood during the period of adoles- 
cence do indicate that the conditions under which the reproduction of 
the species takes place should be deferred till adolescence has passed. 
The love-making of adolescence is not the serious matter it should be, as 
Gwendolen's history well shows : and, therefore, the full physiological 
and psychological conditions for dualism not being there, it should not be 
encouraged. All serious love-making, engagements to marry, too free 
intercourse with the other a(x, too much dancing, too much going into 
society, merely tend to force on the full development, like young plants 
in a hothouse, with the result that the flowers and fruits have a tinge of 
artificialness, do not last, do not stand the same tear and wear. A young 
man who marries before his beard is fully grown breaks a law of nature 
and sins against posterity. A girl who gets engaged while in Gwen- 
dolen's state of mind is not likely to derive all the happiness in marriage 



INSANITIES OF PUBERTY AND ADOLESCENCE. 379 

of which she is capable. It follows, therefore — and most members of our 
profession would, I think, agree with me — that sexual intercourse should 
not be indulged in till after adolescence. 

The period of adolescence is very liable to those psychological cata- 
clasms in weak brains, attacks of mania, that have a special relationship 
to the function of reproduction. Especially it seems to me that the 
periodicity and remission of the nisus generativus in both sexes, and the 
menstrual periodicity which accompanies it in females, are reflected in a 
periodicity and tendency to remission in the insanity that occurs during 
adolescence. 

Passing now from the physiological and psychological characteristics 
of adolescence to the forms of mental disease that prevail then, the fol- 
lowing was a very severe case of the insanity of adolescence terminating 
in recovery : K. Q., aet. 23, a student, who worked hard, who had a 
neurotic heredity, whose life had been sedentary, and whose bodily health 
and nutrition had run down. It was feared, too, he had been given to 
the habit of masturbation. He had been working extra hard to pass an 
examination, when suddenly, without any other exciting cause, he became 
morbidly exalted, lost his power of sleep, got restless, talkative, violent, 
and unmanageable at home. Within four days he had to be sent to the 
asylum. He then labored under acute, almost delirious, mania. He was 
exalted, giving incoherent descriptions of metaphysical speculations and 
mental problems. There was a great deal of the sexual element running 
through his incoherence and his' speculations. His temperature was 
100.1° ; his pulse 84, weak; his weight eleven stone twelve pounds. He 
was kept outside nearly all day in charge of two good attendants, though 
most violent ; he was compelled to take four custards a day, each con- 
taining four eggs and a pint and a half of milk, in addition to any ordi- 
nary food he could be got to take. He was" treated with warm baths at 
night, with cold to his head, and large doses of bromide and iodide of 
potassium combined while the temperature was high. He slept little, 
and in spite of the enormous quantity of nourishment taken he fell off 
in flesh and strength. Contrary to my usual custom in adolescent cases, 
I added a considerable quantity of port wine to his diet, as he looked at 
times so exhausted. In the first six weeks of his stay in the asylum he 
lost two stone in weight. All kinds of sedatives were tried temporarily 
in vain. I thought he was going to die of exhaustion. He had a slight 
beginning of a haematoma, which was blistered, and so stopped. The 
excitement was paroxysmal and recurrent in its intensity, though he was 
never free from it. After about two months the intensity of the maniacal 
condition began to abate, and he passed into what is to me a most anxious 
stage in these cases. His expression of face became enfeebled looking, 
his habits dirty, he masturbated badly, and his whole mental state sug- 
gested dementia rather than either mania or recovery. One cannot pay 
sufiicient attention to the treatment of such symptoms in that stage. Tiie 
nourishment was made a little more stimulating by strong soups, in addi- 
tion to the milk and eggs. He got fresh vegetables, cod-liver oil, with 
the hypophosphites, and strychnine and iron. He was narrowly watched 
and well nursed, and much moral treatment adopted to rouse and interest 
him. It was in truth a toss up between recovery and dementia, between 



880 INSANITIES OF PUBERTY AND ADOLESCENCE. 

mental life and mental death. Fortunately the recuperative power of his 
brain and constitution prevailed, he slowly picked up flesh, and his beard 
and whiskers began to sprout — I have much faith in adolescent recoveries 
when the beard has grown coincidently with recovery — and his weight 
increased fast and steadily, until in six months from the commencement 
of his illness he was quite well in mind, and strong and stout in body, 
weighing thirteen stones. This was one of only about six patients that I 
have seen where recovery took place after a haematoma had formed or 
even been threatened in any degree. 

Such cases are not always so fortunate. Lives that looked full of 
promise are sometimes blasted on the threshold of what seem most bril- 
liant careers, as in the following case of K. R., set. 20. Heredity very 
neurotic, mother being very nervous, aunt insane, and father drunken. 
He had been a most brilliant and successful student, and he had poetic 
gifts that made his friends look forward for his future with much enthu- 
siasm. His illness came on when he was reading hard, sleeping little, 
supporting himself by teaching, and also perhaps further exhausting his 
energy by illicit sexual indulgence. Without any proximate cause he 
became much exalted in mind and much excited, sleepless, and fell off his 
food. The common remedy of enormous doses of morphia was resorted 
to. He got sleep, but was no better for it, and after it would take no 
food whatever. When he came to the asylum he was quite incoherent, 
raving about religion and women. His tongue and lips were dry; his 
temperature 99° ; pulse 144, small and thready ; and his general strength 
small, though his maniacal muscular energy was great. I could get him 
to take no food, so at once fed him with the stomach-pump. He had to 
be put in the padded room at night on account of his delirious violence, 
but was taken out each day into the fresh air by three good attendants. 
He began to take his food after a few days, but remained acutely excited 
for a fortnight. Then there was a remission, but the mania came on 
again, as indeed it did all through his case, by spurts. In about three 
months he began to be more coherent, and wrote some poetry. As it 
illustrates the common mixture of religious and sexual emotion in this 
and most of those cases very graphically, I quote some' of it here: 

A SOLEMN ANTHEM IN CELEBRATION OF THE 
NEW JERUSALEM. 

O, Rosaly, my warm and panting girl, 

Just image to yourself the gates of pearl ! 

The angels sitting in illustrious row, 

Kissing their hands to the Holy Ghost below, 

That glorious unimagined mystery, 

The very hot and lovely Trinity, 

Afar they see the lake of crystal shine. 

Filled with the juice of maidens' paps divine. 

They hear the sappy sound of neighboring love 

And kisses, sacred as the brooding dove. 

They look unto the Great White Throne and laugh. 

Christ plies the Virgin with luxurious chaff; 

Jehovah feels the Queen of Sheba's beauty, 

And refers to the loveliness of Judy. 

The Devil reads the Sermon on the Mount, 

And adds a little on his own account. 

And so they sing their wicked songs together, 

While God in anger frowns upon the weather. 



INSANITIES OF PUBERTY AND ADOLESCENCE. 381 

His bodily health and strength gradually improved, his beard and 
whiskers sprouted in great luxuriance, but his mental power did not 
return. He continued to write poetry, but it got more and more inco- 
herent. He called himself at times "Jesus Christ, Prince Algernon 
Swinburne," though this was scarcely a fixed delusion. He had been an 
intense admirer and great reader of Swinburne's poems, and, as in the 
specimen given above, all his insane poems were influenced by the rhythm 
and by the ideas of that author. The treatment adopted was the same as 
in the previous case, but to no avail as regards his recovery. The change 
to another asylum was tried, but did not rouse him. He sunk into 
dementia in about two years. 

The following patient was not a head-worker: K. S., set. 21. A 
quiet, steady, and intelligent fisherman ; stout, ruddy, and strong in 
body. He came of one of the families of the fishing village of Newhaven, 
that have intermarried for many generations, and in many of which now 
there is an enormous amount of insanity or epilepsy. I know one such 
family where four girls in succession, cousins of K. S., became subject to 
epilepsy and then became insane. If any proof were needed of the 
supreme importance of hereditary influences in the production of mental 
diseases and epilepsy, and the small influence of healthy conditions 
of life in counteracting these hereditary influences in many instances, I 
would point to the village of Newhaven. The people are well-fed fisher 
folks. They are robust and handsome. Most of the "bonny fishwives" 
that are so picturesque an element in the street scenes and street sounds 
of Edinburgh belong to this village. The life they lead is a natural out- 
door one, and yet insanity is more common among them than in any 
community of a similar size I know. That fact along with others, noto- 
riously the frequency of insanity among the old families of the Society of 
Friends, the most self-controlled and virtuous of all religious sects, is a 
complete answer to those who say that mental diseases are mostly due to 
drink and vice and the manifestly bad and unnatural conditions of modern 
town life. But to return to K. S. He at first behaved as if something 
was "preying on his mind," and when questioned could only assign as a 
cause a common dispute in a boat. This was, no doubt, the melancholic 
prelude to the attack. Then he became elevated, and then maniacal and 
violent. This lasted for about a week, and he appeared to be well. In 
a few weeks he again became maniacal, and was sent to the asylum. His 
bodily health seemed absolutely perfect in all respects. He was a fine, 
fresh, ruddy young son of the sea. He was set to hard work in the gar- 
den, and in ten days became rational and quiet, and he has never had 
another attack for now three years. I noticed that during three months 
he was in the asylum his beard and whiskers, which were nascent on 
admission, grew out full and strong, so that, though he came in smooth- 
faced, he left a bearded man. This was a case in which there seemed 
absolutely no exciting cause whatever for the attack but the completion 
of the period of adolescence. 

The following case was one that made a complete and permanent 
recovery after being over a year very ill indeed: K. T., tvt. '22. 
Mother had had puerperal mania. At eighteen he had an attack of 
acute mania, which lasted for two months, and was treated at home. 



382 INSANITIES OF PUBEKTY AND ADOLESCENCE. 

Since then he has kept well, and followed an outdoor occupation, till his 
present attack. Before coming to the asylum he had become maniacal 
again and most violent, the attack beginning with elevation, talkativeness, 
imprudent conduct, disrespect to his father, and generally such behavior 
as looked like mere badness. Many such cases that never reach the 
acutely maniacal stage are put down to vice and drunkenness. He was 
sent to the country with an attendant, and seemed to recover in a fort- 
night. He then returned home, but in a month from the beginning of 
the second attack he became maniacal again, and was sent to the asylum. 
While there he had five violent attacks of acute mania, at pretty regular 
intervals over twelve months, and then recovered. One of these attacks 
was longer than the rest, and was attended with considerable emaciation, 
dirty habits, and demented expression of face, and I was afraid of 
dementia, but the treatment I have described was most energetically per- 
sisted in, and he recovered. It is a very interesting study to watch such 
a case from day to day and week to week. I consider that if the daily 
loss of flesh, which will occur for perhaps the first few weeks and during 
the acute and sleepless stage, is checked soon, and the patient ceases to 
lose weight, that it is a good sign. I encourage the attendants to feel in 
those cases that they are fighting the disease with milk and eggs and fresh 
air, and to interest them in the case by letting them weigh their patients 
every few days. A good attendant will show a lively interest in the 
contest with the disease, and will feel a sense of personal elation or defeat 
as weight is gained or lost. After dementia has set in, body weight may 
be gained with no corresponding mental improvement ; but a gain in 
weight within the first six months, or even the first year, means that 
recovery is probably going to take place ; and within that time everything 
that tends towards increased body weight tends towards recovery. 

The last case I shall refer to is one where recovery did not take place, 
but dementia resulted. K. Y., aet. 16. Has an aunt in the asylum. 
Had been a month ill before admission. He v\'as excited, noisy, shouting, 
and dancing about. That was in 1878. For four years he was subject 
to attacks of acute maniacal excitement at intervals of a few months. In 
the first year they were very acute. This is a general rule. My expe- 
rience is that the first attack or the second is apt to be the worst. In 
K. V.'s case the attacks got less acute after the first year, but in the in- 
tervals between the attacks he was less sane. A clouding process over 
his mind went on, each attack leaving him rather more enfeebled than the 
last. But he was once so well that he was tried at home for a short time. 
He gradually sunk into secondary dementia, with rare and occasional 
spurts of restlessness and mild maniacal excitement at irregular intervals 
— a type of the healthy chronic lunatic that forms half the population of 
most asylums, and he is likely to live for many years. Ke can work in 
the garden, can answer questions, sleeps well, is not uncleanly in his 
habits, mingles in the asylum amusements, but all his "higher nature" 
is gone. He cares little for his relations. His joys and sorrows are 
very mild. He has no interest in life, no ambition, no great sense 
of right or wrong, no volition in any higher sense, and no religious 
instinct. 



INSANITIES OF PUBERTY AND ADOLESCENCE. 383 

Treatment of the Insanity of Adolescence. — The treatment I 
have lately adopted for such cases is founded on physiological considera- 
tions. The completion of the period of adolescence is in both sexes 
accompanied by a considerable deposit of adipose tissue, by an overplus 
of strength and activity, and by a state of general good nourishment of 
the body. To attain to this normal condition of body should undoubtedly 
be our aim in treating all cases of mental disease at this period. It 
always seemed to me that there were two things that constantly worked 
the other way, and that I had to contend against in their treatment. 
These were the general brain excitability and the morbid strength, and 
often perversion, of the generative nisus. The one tended to mania, 
sleeplessness, purposeless motor action, thinness, and exhaustion ; the 
other to erotic trains of thought, sexual excitement, and masturbation. 
I found that inaction, reading, indoor life and amusements increased the 
one, and novel-reading, solitariness, and long hours in bed aggravated 
the other, while animal food and alcoholic stimulants gave increased 
strength to both morbid tendencies. I therefore put my patients to 
active exercise in the open air for as many hours a day as possible, 
walking, digging in the garden, wheeling barrows ; I give them shower- 
baths in the morning when the weather is suitable and they are strong 
enough, and I encourage active muscular exercise in every way. Athletic 
games of all sorts in the open air are certainly good so far as they go. I 
place great reliance on the diet. Milk in large quantity, and as often in 
the day as possible, bread, porridge^ and broth are the staple articles of 
food for such patients here. My friend Dr. Keith, of this city, was the 
first to direct my attention to the advantage of a light, farinaceous, and 
milk diet in another class of cases, and my experience is strongly in 
favor of his views. The patients may have some fish, or fowl, or eggs, 
but in reality milk is the most important means of treatment. I seldom 
give such cases alcoholic stimulants. I give to all such patients who can 
take and assimilate it easily an emulsion of cod-liver oil, hypophosphite 
of lime, and pepsine, made and flavored in such a way that it resembles 
cream. I find very few indeed who cannot take this. Beyond this, an 
occasional bitter tonic, with sometimes a chalybeate or some of the new 
compound syrups of the phosphates, are about all the medicines I give. 
The effect of this diet, regimen, and treatment is very marked in the 
majority of cases. No doubt during the first part of the attack the 
patients may lose weight while the excitement is in its most acute stage ; 
but they soon begin to gain weight, and my prognosis is always favorable 
when I find a patient beginning to gain weight within a reasonable time, 
say six months or so. I have had patients who, in spite of very sharp 
excitement indeed and much sleeplessness, gained weight under this treat- 
ment. It seems to me that the process of fattening such a patient, and 
the conditions under which it takes place, are antagonistic to the disease 
and its results. I have known the stopping of the cod-liver oil to bo 
followed at once by a loss or diminished gain in weight, and its resump- 
tion to be followed by the former rate of increase. If a young man or 
woman suffering under the insanity of adolescence is found to gain one 
or two pounds a week within the first three months, I look on him as quite 
safe. It is common to gain a stone in a month. 



384 INSANITIES OF PUBERTY AND ADOLESCENCE. 

I have now pursued this plan of treatment long enough to yield results 
that can be relied on, and I believe that more of my patients recover than 
before I adopted it. They recover sooner, and their recoveries are more 
reliable and permanent. Even in the case of those who sink into de- 
mentia, I think they do so more quietly and with less of the element of 
chronic mania than under a flesh diet. It is, I think, certain that the 
habit of masturbation, which is so frequent and so deleterious in such 
cases, is less practised by patients on this diet, and, when practised, is 
less damaging to brain function, and takes less hold on them. 

Lastly, in connection with this subject, I would say a word about pro- 
phylaxis in children with a strong neurotic inheritance. My experience 
is that the children who have the most neurotic temperaments and dia- 
theses, and who show the greatest tendencies to instability of brain, are, 
as a rule, flesh-eaters, havinor a cravino^ for animal food too often and in 
too great quantities. I have found also a large proportion of the adoles- 
cent insane had been flesh-eaters, consuming and having a craving for 
much animal food. It is in such boys that the habit of masturbation is 
most apt to be acquired, and, when acquired, produces such a fascination 
and a craving that it may ruin the bodily and mental powers. I have 
seen a change of diet to milk, fish, and farinaceous food produce a marked 
improvement in regard to the nervous irritability of such children. And 
in such children I thoroughly agree with Dr. Keith, who in Edinburgh 
for many years has preached an anti-flesh crusade in the bringing up of 
children up to eight or ten years of age. I believe that by a proper diet 
and regimen, more than in any other way, we can fight against and 
counteract inherited neurotic tendencies in children, and tide them safely 
over the periods of puberty and adolescence. 

The following is a statistical and clinical inquiry into the subject of the 
insanity of adolescence. Eor this inquiry I took for the period of five 
years and a quarter (from 18T4 till the end of the first quarter of 1879) 
all the cases that were admitted into the Royal Edinburgh Asylum. 
They amounted to 1796 — 917 men and 879 women. Of these, 320 
were between the ages of 14 and 25, viz. : 195 males and 125 females. 
Now, if my object had merely been to arrange those 320 patients each 
in a classification of symptoms, it would have been simple enough : so 
many with exaltation under "Mania," so many with depression under 
"Melancholia," etc. That was done, but a great deal more informa- 
tion must be expiscated about each case if we are to arrange them in 
clinical or physiological groups, and especially if we are to have any 
light thrown on the question — " Did adolescence influence the mental 
symptoms present in those cases?" We must ask and answer the fol- 
lowing inquiries : "In how many cases did the disease exist before the 
age of 14, or was of a kind with which adolescence could have nothing to 
do ?" I found I had to deduct 90 such cases, or about one-third of the 
320 who had been mentally defective or epileptic from birth, or very 
early ages, or labored under organic disease, or in whom the disease 
came on in nursing or childbirth, leaving 230 in whom it was possible 
for puberty or adolescence to cause or influence the disease. 

The next inquiry naturally was — " If 230 occurred in the twelve years 
between the ages of 14 and 25, is that number greater or less than is 



INSANITIES OF PUBERTY AND ADOLESCENCE. 385 

found in the same number of years at other ages?" I find it to be far 
more than between 2 and 14, but less (10 per cent.) than between 30 
and 40. At this particular age, either from adolescence or some other 
cause, it is clear that there arises a liability to insanity which did not 
before exist, but which does not cease when adolescence is past. 

The next query was this : " Taking this long period of twelve years, 
is there any special liability during any of the years of that time?" 
" Does it arise at puberty, or towards the completion of the period of 
adolescence?" A glance at the numbers who became insane in each of 
the twelve years shows that the first two, that is the 14th and 15th, were 
especially exempt, only producing one case each ; and the next two, the 
16th and 17th, also very few (22). Now the fact that there only occurred 
in those four years of life 24 cases out of about 1800 in all (230 of them 
being adolescents and healthy up to that period), does show clearly that 
the first onset of the reproductive function is not a dangerous one as re- 
gards liability to insanity. 

The next three — the 18th, 19th, and 20th — are still low, producing 
only 49 cases, or an average of 16 in each year. In those three years, 
while puberty has occurred in nearly every individual of both sexes, yet 
adolescence has not been completed in many of them. 

It was in the next five years, from the 21st to the 25th, that the vast 
majority of the cases occurred, viz. : 157 of the 230, or an average of 31 
in each year as compared with an average of 8 for each of the first five 
years. At 14 and 15 the liability to insanity was practically mZ, from 
21 to 25 it was very great. In fact, a comparison with the liability at 
other ages during the past five years in the admissions to the asylum 
shows that there is no period of life in which uncomplicated insanity occurs 
more frequently than during the completion of the physiological era of 
adolescence, from 21 to 25. It must be kept in mind that I am not now 
speaking of the numbers becoming insane in proportion to the number of 
the general population alive at any particular period. 

Comparing the two sexes, the total numbers and relative proportion of 
females are smaller in the adolescent period than at later periods of life. 
Adolescence does not appear to be so powerful an upsetter of mental 
equilibrium in women as in men. 

Having elucidated these points, we come to the question as to w^hat 
mental symptoms these adolescents suffered from, and if those symptoms 
were in any way peculiar ? While investigating this, I found the com- 
plications of marriage, childbearing, and lactation in the females so 
common after the age of 21, that it was difiicult to compare them with the 
males. I therefore made 21 the limit of age for them. This reduced 
their numbers to 40, making, with the 140 males, 180. 

The first fact of importance is, that there were only 40 cases in which 
the symptoms present were classed as states of mental depression or 
melancholia, while the rest were cases of exaltation or mania. Now, the 
significance of this proportion is only seen by comparison. During the 
past five years in the asylum there have been admitted two cases of un- 
complicated mania to one of melancholia (849 to 439), whereas among 
the adolescents it was SJ to 1 (140 to 40). And if we compare them 
with those at more advanced ages, e.g., women at the climacteric period, 

25 



386 INSANITIES OF PUBERTY AND ADOLESCENCE. 

the proportion of mania to melancholia is reversed, there being only one 
case of the former to If of the latter. 

The proportion of states of exaltation of mind or mania, therefore, is 
much greater as compared with those of melancholia among the adolescent 
insane than among the insane at all ages, this excess being still more 
marked when compared with the cases of mental disease occurring at the 
climacteric period of life. 

The next inquiry was — " What was the character of the mania?" I 
found that it had several well-marked characteristics. It was, in the first 
place, often of a very acute, though seldom of a delirious type ; in the 
second place, it was mostly of short duration, the patients getting soon 
apparently quite well ; in the third place, the patients were subject to 
constant relapses. Out of the 180 cases, 118, or Q6 per cent., had such 
intermissions of sanity with subsequent relapses. This tendency to short, 
sharp attacks, with intermissions of more perfect sanity than occurs in 
most other kinds of mental disease, with relapses occurring one, two, 
three, four, and five times, and even more frequently, before recovery or 
dementia finally takes place, may be taken to be especially characteristic 
of this insanity of adolescence. In many of them, as the maniacal attacks 
passed off, there was a slight tendency to melancholia, a sort of reaction 
no doubt. This was noticed in 62 cases. This relapsing character with 
the tendency towards depression brings adolescent insanity into relation- 
ship with foUe circulaire. The real cause of the remissional character 
of both is no doubt the periodicity of the generative power and desire in 
their greatest intensity. 

Another well-marked characteristic was this, that a hereditary predis- 
position to mental disease, or at least to some of the neuroses, was present 
in 77 of the 180, or in 45 per cent, of the whole number. It is very 
diflBcult to get family histories of insanity in most cases, and you may 
multiply by two those you get, if you want an approach to the truth. 
The proportion of hereditary predisposition in the asylum, as recorded in 
our case-books, is only 23 per cent, as compared with the 45 per cent, 
among the adolescents, in whose cases no special pains had been taken 
to ascertain family histories. I observed a still more striking fact in 
regard to the heredity of the insanity of adolescents. I happened to 
have a personal knowledge of the history of the cases or of the families in 
fifteen of the cases, and in twelve of these there was a hereditary predis- 
position to the neuroses. The insanity of adolescence is therefore pre- 
disposed to in most cases by a nervous heredity, being one of the most 
hereditary of all forms of mental disease. 

.Another marked character of the mania was that the ideas, emotions, 
speech, and conduct wxre all strongly tinctured by the mental charac- 
teristics of adolescence in an exaggerated or morbid way. That per- 
version of the sexual act, the habit of masturbation, was very common, 
probably existing in over 50 per cent, of the cases, aggravating the 
symptoms, and diminishing the chances of recovery. In the females 
hysterical symptoms were common, such as mock modesty, simulated 
pains, and a desire to attract attention. In the males heroic notions, an 
imitation of manly airs and manners, an obstrusive pugnaciousness, and 
sometimes a morbid sentimentality were present. In almost all the cases 



INSANITIES OF PUBERTY AND ADOLESCENCE. 387 

the physical appearance of the males was boyish when the attack com- 
menced ; and most of the females were girlish rather than womanly in 
contour. 

As regards the results of treatment in those cases, 93 were discharged 
recovered, or 51 per' cent. ; but then 40 were removed home or to other 
institutions relieved, many of whom would have been likely to recover 
ultimately. I only know of 26 of the 180 who became incurable. In- 
sanity occurring at the adolescent period is, therefore, a very curable 
disorder, as compared with many other forms, though not so curable as 
some others, e. g,, puerperal insanity. Just before recovery, in almost 
all the cases which did get well, signs of physiological manhood appeared, 
the beard growing, the form expanding, the weight increasing. When- 
ever I see those signs, accompanied by mental improvement, I am in- 
clined to give a favorable prognosis. The mortality was very low, only 
three of the 180 cases having died. 



LECTURE XYII. 

CLIMACTEKIC INSANITY— SEXILE INSANITY. 

As unstable brains are apt in certain cases to be upset in their mental 
functions by the oncoming of the reproductive power and the sexual 
desire at the periods of puberty and adolescence, so they are apt to suffer 
as those great powers of the organism pass away at the climacteric period. 
An animal has functionally and physiologically three distinct periods of 
existence — (1) when its life is dependent on that of its mother before 
birth ; (2) when it lives independently, but cannot reproduce itself, before 
puberty and after the climacteric ; and (3) when it both lives and can 
reproduce. The mental function is non-existent in the first period, more 
or less imperfect in the second, and fully developed in an ideal sense only 
in the third. At the period of the climacteric there is unquestionably a 
normal mental change in both sexes. The sexual desire invariably 
weakens in its intensity or ceases altogether, and with it the affectiveness 
changes in its object and greatest intensity from the mate to the progeny, 
losing its imaginative force, its fire, and its impulsiveness. Poetry and 
love tales then cease to have the power "to set the brain on fire." 
Action of all kinds ceases to be so pleasurable for its own sake as it has 
been before. Much of "the go is out" of the person. The instinctive 
feeling of difference of sex, and all that it implies, which has been all- 
pervading before, now lessens visibly. The subtle interest of the society 
of the other sex is less electric and overmastering. Along with these 
affective changes there are bodily changes too. The form alters, especially 
in women, and the expression of face changes, the ovaries shrivel, Peyer's 
patches lessen in bulk, and the spleen and lymphatic glands harden. 
The blood-forming and the blood-using processes slacken in speed, and 
the trophic energy in all the tissues is less intense in action. "Life 
becomes slower," in fact, mentally and physically. And as a result of 
this, after the climacteric has been safely passed, the organism is less 
liable to many diseases than it has been before. The real climacteric 
period in both sexes is never a definite fixed time, but usually extends 
over a year, or two, or three. The mere cessation of the function of 
menstruation in women does not necessarily fix definitely the mental and 
nutritional changes that mark the period. I have known a woman of 
fifty who had gone through the mental changes of the climacteric, yet in 
facial expression and in shape was post-climacteric, who had no sexual 
desire, yet was menstruating regularly ; and, on the other hand, I have 
known many women of the same age in whom menstruation had ceased 
from forty to forty-six, who were yet quite shapely, amorous, and men- 
tally youthful. So the mental disease that accompanies the climacteric 
need not be quite coincident with the menopause, but may occur some 



CLIMACTERIC INSANITY. 389 

time before or some time after that event. As a matter of fact, the 
ordinary sensory nervous symptoms that are connected with the climac- 
teric in women, viz., giddiness, flushings, flashes of light, uneasy organic 
sensations, usually precede the actual cessation of the menses rather than 
accompany it. 

A typical case of climacteric insanity begins by a loss of energizing 
power, bodily and mentally, of which the patient is rather supersensi- 
tively conscious. Her courage fails ; little things come to have the 
power of annoying her that she would have thought nothing of before. 
Groundless fears, which at first she knows to be groundless, haunt her at 
times. And at this stage the sleep is apt to be dreamy and broken, the 
appetite for food is less intense, and the bowels costive. There is apt to 
be some falling ofi" in freshness of the complexion and in looks generally. 
The skin often gets muddy, and more pigmented than usual. It is a 
trouble for her to go into company or to move about in public, and yet 
she has no restful feeling and no contentment or organic happiness. At 
the menstrual times all these things are much worse, and there is apt to 
be real depression of mind, weeping, with irritability of temper and 
sleeplessness. I have never yet met with a climacteric case in this early 
stage who did not feel much better in the open air than in the house. 
That is an indication of treatment and of prevention of further symptoms 
that I never fail to find useful. I have seen iron at this stage, too, do 
very much good ; in fact, it seemed to act as a specific. But those symp- 
toms do not constitute insanity, though they are essentially mental dis- 
order. 

The next stage consists of more real and continuous depression. The 
morbid fears assume a more intense character, though they are often still 
indefinite. The patient is quite sure some evil thing is going to happen 
to her, though she cannot tell what it is to be. The self-control is often 
lost, but much more frequently the patient is terrified that it is going to 
be lost. There are vague impulses towards suicide, sometimes towards 
hurting husband and children, and the existence of these add to the terror 
and intensify the depression. Such things are thought by the patient to 
be ''so wrong," and she blames herself for them. A conscious loss of 
affection, or rather a loss of the pleasurable feeling that conscious aff"ec- 
tion for husband and children gives, is a cause of the greatest distress. 
There is often a sort of organic repugnance to the husband and to his 
attentions. By this time all the usual sensory accompaniments of the 
climacteric have disappeared, or rather they have been transformed into 
the mental neurosis I am describing. There are no headaches, or giddi- 
ness, or flushings. But the trophic neuroses become aggravated all the 
time. The thinness, the flabbiness of muscle, the pigmentation of skin, 
get worse. There are frequently skin irritations, and the patient picks 
and scratches her skin. The boAvels are costive, the appetite gone, the 
sleep absent, and the capacity for work greatly lessened. 

In the worst cases, suicidal feelings are strong and attempts frequent, 
but tliey are rather apt to be feeble. The very loss of courage and vigor 
of will operates against any effectual attempts at suicide, however much 
the wish may be there. Hallucinations of hearing are frequent. This 
condition may pass into acute excited melancholia and exhaustion, and 



890 CLIMACTERIC INSANITY. 

death ensue, or it may become a sort of chronic shy uselessness, or 
"paralysis of energy," or it may gradually pass away under proper 
treatment and conditions of life, and the woman become strong, cheerful, 
well-nourished, and useful, more "healthy" in a certain sense at all 
events than ever. 

The following is a case of climacteric insanity, of short duration but 
very acute form, and with an element of stupor. 

K. v., set. 46, of a cheerful and sociable disposition, and good habits, 
but with some heredity to insanity and the neuroses, a sister having been 
insane, and a child having died of hydrocephalus. My impression is 
that, of all the expressions of an heredity to insanity in childhood, 
hydrocephalus is, next to convulsions, the most common. The whole 
question of the transmission of neuroses to children by mothers who are 
then to all appearance healthy, and in whom any nervous disease is a 
mere potentiality, is very interesting, and stands in need of accurate 
observations. The weak and troublesome point of all studies of heredity 
is that they cannot be regarded as complete till all the subjects of them 
are dead. K. V. had over-exertion of body and anxiety of mind in 
nursing her husband and through his death, just as she was becoming 
irregular, this being the exciting cause of her attack. She became irreg- 
ular in her menstruation, but had not many of the usual sensory accom- 
paniments of the climacteric. My experience is that in the climacteric 
cases with a mental neurosis, the former are often enough absent. The 
one seems to come instead of the other. She never slept well after her 
husband's death. In about two months thereafter she became depressed, 
and suspicious that her neighbors had an ill-will to her and that everyone 
was against her. It is easy to see how a lone, neurotic widow, with a 
family to support, should take such ideas. But by and by she began to 
fancy that her friends put poison in her food ; no doubt this was the 
misjudged sensation of the pain of dyspepsia. Then she began to groan 
most of the time, and to cease to attend to her work, or to take an interest 
in anything, her whole mind being absorbed in her morbid thoughts. On 
being sent to the asylum, she picked up to some extent at once, exercising 
all the self-control she was capable of, the very unpalatableness of the 
situation rousing her. She was thin and dark-skinned, and had a dull, 
listless look. Her sensibility to pain was dulled, there being an element 
of mental stupor in her case. The tongue was furred and tremulous, and 
the bowels costive. Her pulse was 88, weak; her temperature 99.3° ; 
and her weight only eight stone eight pounds. She was much depressed 
and confused, mistaking the identity of people about her. She slept 
very little at first. Her appetite was poor, and her notions of cleanliness 
and decency were meagre. She was ordered quinine and iron, warm 
baths, exercise in the fresh air, simple laxatives, and proper supervision 
and nursing. In a fortnight she was sleeping better, in a month she was 
sleeping well. She took plenty of food, occupied herself in useful work, 
and her skin began to look clearer and more healthy. Her fears and 
delusions became vague, and with less influence on her demeanor. She 
would then take a good fit of crying, which did her good. In another 
month she had gained over a stone in weight, and was fairly convalescent, 
and being much needed at home, was sent there perhaps earlier than 



CLIMACTERIC INSANITY. 391 

might otherwise have been desirable. The disease in such short cases 
has little tendency to recur. When she left she was getting the post- 
climacteric look. 

The following case is one in which the symptoms of climacteric insanity 
came on several years after the menopause, were never very acute, yet 
the woman has not got over them for two years. She is rational in 
conversation, and has no delusions, and her depression is by no means 
acute, but she is so absolutely devoid of initiative power and energy that 
she remains voluntarily in the asylum, and is quite unfit to do her work 
in life. K. W., aet. 51, a widow, a healthy, cheerful, active woman, who 
had two children, and no heredity to insanity. About forty-five, so far 
as she remembers, she ceased to menstruate, this being accompanied by 
fearful headaches, feeling sometimes as if she would " go out of her 
mind." Those headaches continued more or less up to the onset of her 
present attack of melancholia, but she did not change in facial expression, 
and did not lose her shape, in fact did not exhibit the usual bodily signs 
of having passed the crisis, till the depression of mind began to appear. 
At fifty-one, without any cause, she became depressed in mind, nervous, 
anxious, and fearful. She gradually developed the delusion that her 
friends wished to take her life. She was sleepless, and once threatened 
to throw herself out of the window. She lost all hope and courage and 
interest in life. She got occasidnally excited and lost her self-control, 
which was the cause of her being sent to the asylum, but during the two 
years she has been there she never has shown any sign of excitement, 
except on one occasion slightly. She has simply been a dull, anxious, 
retiring person, morbidly fearful of giving offence, and having a dread on 
her that something fearful is going to happen to her. She has eaten and 
slept well. She does what she is told without interest. She has vague 
semi-delusional ideas that her friends are all dead, that the people here 
seem to be the same as her former friends, that the things and people 
about here are not real. She has those feelings, yet she does not really 
believe them. She has pains and numbnesses in her joints and her limbs, 
probably neurotic in origin. She eats well — far more, she says, than she 
ever did before — looks stout and well, sleeps well, and is muscularly strong, 
though not alert or active. She leads a dependent life, with no joy in it 
at all or no interest in anything, but with little intellectual impairment in 
the sense of dementia. She shoAvs no sign of recovery and no sign of 
getting worse. Yet I think recovery perfectly possible in her case, for 
I have seen such cases recover after several years. She lives on a lower 
plane emotionally, and as to energy and spontaneity. She never laughs, 
but never cries, and never loses her temper. She has no pleasure in social 
intercourse, but she does not shun her fellows. This is to me just an ex- 
aggerated and morbid type of post-climacteric physiological and psycho- 
logical life. 

Some of the cases take a long time to recover. I never give up hope 
of recovery in a climacteric case for four or five years, except there are 
symptoms of dementia or fixed delusions. The physiological period of 
life not being a fixed or always a short time, therefore its morbid, nervous, 
and mental accompaniments are often prolonged and irregular. 

The period of the climacteric in the male sex occurs at a later time of 



392 CLIMACTEKIC INSANITY. 

life than in the female, and is much more irregular and indefinite. There 
is nothing to mark it off so clearly as the menopause. Sexual power re- 
mains, but the appetite for it is not in normally constituted persons keen 
or pervading. There is little or no self-control needed to restrain it, as 
in earlier years, and indeed it is commonly dormant, except when stimu- 
lated. The common age for the ''grand climacteric" in man is from 
fifty-five to sixty-five, a few cases occurring before and after those ages. 
The popular tradition puts it at sixty-three. The procreative power of 
man has been demonstrated by statistics to become progressively less 
after fifty, and to be in reality small at the latter age. The normal 
mental change in man is essentially the same as in woman. 

The abnormal mental changes that are seen in some cases at the 
climacteric period in men are the same in general type, too, as in women. 
The spontaneity, the courage, the mental aggressiveness, the necessity to 
energize actively, the poetic sentiment, the keenness of feeling in all di- 
rections, all these are impaired. There is no drawing towards the other 
sex, and no subtile delight in its presence. The sleep is less sound and 
shorter. A cloud of vague depression rests on the man, who shuns 
society, falls off in fat, becomes restless and hypochondriacal, and feels 
^strongly the tedium vitce. This may go on to suicidal longings and 
desires, which are usually not very intense. In fact, nothing is intense 
with the man. His energies, his functions, and his vitality have all been 
lowered. With this there is no atheroma, arcits senilis^ or proper senility. 
The following was an aggravated case of senile insanity in the male sex : 
K. X., set. bQ. A quiet man, of melancholic temperament, steady and 
industrious in his habits, and with no known heredity to insanity. Lately 
he had little work and not much food, and was therefore anxious and 
underfed. He gradually became dull, and possessed with the fear that 
something dreadful was going to happen to him and his family — a fear 
founded on realities at first, but gradually assuming a delusional character. 
He became taciturn and wearied of his life, ceased to take any interest in 
anything, and could not be roused. One morning, just before coming 
into the asylum, he told his wife to get up at once and conceal herself, 
as he had a strong desire to kill her and others. On admission he said 
he felt very badly, that strange and frightful ideas came into his head 
and preyed on his mind. One minute he was looking the picture of 
misery and sitting quite still, then he would lose control over himself 
and become restless and impulsive, and strike and bite those near him. 
He was thin, pale, flabby in his muscles, and his skin dark, muddy, and 
pigmented. He had been blistered at the back of his head before ad- 
mission (blisters are good treatment for some cases of insanity, but not 
for a half-starved, melancholic workman at the climacteric). He had a 
vague, indefinite dread on him, and an absolute lack of interest in any- 
thing in life, though his memory and general intelligence were good. 
His tongue was foul, his bowels costive. There were no visible signs of 
atheroma of the arteries. He took his food fairly well at first, and was 
ordered extra diet, porter, and Parrish's syrup of the phosphates. He 
improved considerably for the first six months in body and mind, but he 
never got to enjoy life or to be sociable. After that time he got worse, 
did not take his food well, and fell off again in flesh. Everything was 



CLIMACTEEIC INSANITY. 393 

done to improve his appetite, and nourishment, quinine, cod-liver oil, the 
phosphates and hypophosphates, garden work, and amusements were all 
tried, but he got steadily worse. He became more solitary and silent. 
His blood got so abnormal that at one time purpuric spots appeared over 
his legs. His delusions assumed more of a hypochondriacal character 
before his death, which took place two and a half years after admission. 
He thought all his organs were diseased, and that .he had no stomach. 
He died suddenly at last, being then a mere skeleton from exhaustion. 
The brain convolutions were found to be atrophied and very anaemic ; the 
arteries had begun to show the atheromatous degeneration ; there were 
some granulations on the floor of the fourth ventricle, and the lateral ven- 
tricles were dilated and filled with a pink serum. There was a patch of 
white softening, about the size of a filbert, in the centre of the left 
hemisphere. The aorta was markedly atheromatous. This case had not 
had during life any of the distinctively senile mental characters, yet the 
pathology was undoubtedly like that of many senile cases. 

Of a much more common type was the following less aggravated case : 
K. Y., set. 57, a professional man, who had worked very hard indeed. 
He had a slight and distant heredity to mental disease. His professional 
Avork became a burden to him, and he lost all confidence in doing it, so 
that he had to give it up. He did not sleep well, became much depressed, 
and was very miserable, obstinate, and hypochondriacal. He had quite 
made up his mind that he was not to get better, and would do nothing 
towards his own cure. He did not lose his self-control. He simply 
changed his habits, avoided his friends, neglected his personal appearance, 
was absolutely idle, and might be said to have become morbidly "selfish." 
With all this there was apparently no lack of reasoning power, or general 
intelligence, and this made the whole thing the more trying to his friends. 
When a man who cannot reason acts unreasonably allowance is made for 
him, but when a man acts unreasonably who can reason, the natural 
impulse is to blame him and hold him fully responsible. Fortunately he 
did not give up going out into the fresh air, and this was his ultimate 
salvation, for he slowly improved, and in the course of about five years 
he got perfectly well, and resumed his business, though he never could do 
as much, and was never " quite the same man," but was about as happy 
as the average of his fellow-men in their post-climacteric. No doubt if 
he had taken to his bed, or to staying in the house, as so many such cases 
do, he would never have recovered. In his case, as that of many others 
I have met with, the first decided symptoms of mental improvement were 
coincident with an eczematous skin eruption. I have seen gouty, 
syphilitic, and all sorts of skin eruptions come on in such cases during 
the disease, usually greatly to the patient's mental benefit. 

The prognosis and other points in climacteric insanity are best brought 
out by a statistical study of a number of cases. In the nine years 
(1874-1882) I have diagnosed as such two hundred and twenty-eight 
cases of the thirty-one hundred and forty-five that have been adnutted 
into the Royal Edinburgh Asylum in that time. Of these the large ]iro- 
portion of one hundred and ninety-six were women, and only tliirty-two 
being men. The table below shows their ages. 

We see that by far the majority of the female cases occurred between 



394 CLIMACTERIC INSANITY. 

forty and fifty, and the majority of the men between fifty-five and sixty- 
five. As regards the symptomatological forms assumed by the cases, only 
thirteen of the men and fifty-six of the women, or eighteen per cent, of 
the whole, were acute in character. It is essentially, therefore, a 
subacute psychosis in its general character. Of the whole, only eighty- 
two were cases of mania, the remaining one hundred and forty-six being 
melancholic. One-half the patients were suicidal in intent at least, but 
few of them have made very serious or desperate attempts to take away 
their lives, though to this there were some exceptions. There was a high 
proportion, but a low intensity of suicidal impulse. 



Ages. 


Males. 


Females. 


Total 


35 to 40 




17 


17 


40 " 45 




74 


74 


45 '• 50 




81 


81 


50 " 55 


7 


19 


26 


55 " 60 


14 


5 


19 


60 " 65 


9 




9 


65 " 70 


9 




2 



32 196 228 

The results of treatment showed that one hundred and twelve cases, or 
fifty -three per cent, of them, recovered, the women recovering in the 
largest proportion. In fact, only thirty-one per cent, of the men got well, 
while fifty-seven per cent, of the women did so. The numbers who died, 
on the contrary, were greater proportionately in the men than the 
women, four of the former, or twelve per cent., and seventeen of the latter, 
or nine per cent., having died up to this time. This would seem to 
indicate that the disease is rarer, less cui'able, and more deadly in the 
male sex than the female ; but the numbers are perhaps too few on 
which to base a correct generalization. 

The patients who recovered had not been so long ill as I had previously 
imagined. Taking the time they were under treatment in the asylum 
(the only correct basis I have on which to estimate the duration), sixty- 
one of the one hundred and twenty-two who recovered, or fifty-five per 
cent., were discharged within three months, and eighty, or sixty-five 
per cent, within six months, and one hundred and eleven, or ninety-one 
per cent., within twelve months. There were a few patients who 
recovered after two years of treatment. The maniacal and the melan- 
cholic cases recovered in about equal proportion, but the maniacal in 
shorter time. The recoveries were much fewer in the women over fifty, 
only twenty-nine per cent, of these getting better. Up to fifty they 
recovered equally well. At the other ages, fi'om fifty-five to sixty, the 
cases were the most curable in the men. Only three of the eleven over 
sixty got over their malady.^ 

^ These statistics may be profitably compared with those of Dr. Merson's admirable 
paper on this subject, in the We>t Riding Lunatic Asvlum 3Iedical Reports, vol. vi. 
p. 85. 



SENILE INSANITY. 395 



SENILE INSANITY. 



The psychology of normal old age has yet to be written from the 
purely physiological and brain point of view. Poets, dramatists, and 
novelists have had much to say of it from their standpoint. King Lear 
is beyond a doubt a truthful delineation of senility, partly normal and 
partly abnormal. By normal senility I mean the purely physiological 
abatement and decay in the mental function running pari passu with the 
lessening of energy in all the other functions of the organism at the latter 
end of life. No doubt, in an organism with no special hereditary weak- 
nesses and that had been subjected to no special strains, all the functions 
except the reproductive should decline gradually and all together, and 
death would take place, not by disease in any proper sense, but through 
general physiological extinction. The great function of reproduction 
stands in a different position from all the other functions of the organism. 
It arises differently, it ceases differently, and it is more affected by the sex 
of the individual than any other function. It is, as a matter of fact, not 
entirely dependent on individual organs. It may exist as a desire and an 
instinct without testes, or ovaries, or sexual organs. It is really an essential, 
all-pervading quality of the w^hole organism, and to some extent of every 
individual organ, not one of which has entirely lost the primordial fissi- 
parous tendency to multiply. But the physiological period of the 
climacteric has determined and ended it in its intensity and greatest power, 
though many of its adjuncts remain ; and in the male sex we have to 
reckon with it and its abnormal transformations to some extent even in 
the senile period of life. 

Physiological senility typically means no reproductive power, greatly 
lessened affective faculty, diminished power of attention and memory, 
diminished desire and power to energize mentally and bodily, lowered 
imagination and enthusiasm, lessened adaptability to change, greater 
slowness of mental action, slower and less vigorous speech as well as 
ideation, fewer blood-corpuscles red and white, lessened power of nutrition 
in all the tissues, a tendency to disease of the arteries, a lessening in bulk 
of the whole body, but notably of the brain, which alters structurally and 
chemically in its most essential elements, the cellular action and the nerve 
currents being slower, and there being more resistance along the con- 
ducting fibres. 

In the young man there is an organic craving for action, which, not 
being gratified, there results organic discomfort ; in the old man there is 
an organic craving for rest, and not to gratify that causes organic uneasi- 
ness. 

The three great dangers to normal mental senility are hereditary brain 
weakness, a diseased vascular system, and the after-effects of over- 
exertion or abnormal disturbance of brain function at former periods of 
life which have left the convolutions weakened. The hereditary predis- 
position to mentd disease that has not shown itself till after sixty must, 
no doubt, have been slight or well counteracted in the eonditions'of life, 
yet in many brains it never shows itself till then. Until the organ liad 
begun physiologically to lose its structural perfection and its dynamical 



396 SENILE INSANITY. 

force, the pathological phenomenon that we call mental disease was not 
developed. As we shall see from a statistical study of clinical cases, 
heredity to insanity was less common in the cases of senile insanity than 
in any other form of mental disease except general paralysis ; but there 
is this fallacy, that the facts about heredity w^ere further back and more 
forgotten in this than in any other form. An old man's living relatives 
are few, and his ancestors' history far off. We may put it down as 
a certain law of nervous heredity, that the stronger the predisposition the 
sooner it manifests itself in life, and the weaker it is the later in life it 
shows itself. To have survived, therefore, the changes and chances, the 
crises and perils of life with intact mental function till after sixty, means 
slight neurotic heredity or great absence of exciting causes of disease. 

It is impossible to fix an age at which physiological senility begins, and 
therefore we cannot fix an age for senile insanity. Some men are older 
at fifty than others are at seventy. I believe that in some cases neurotic 
heredity assumes the special outcome of early senility — that is, of early 
wear-out or poor organic staying power. Most congenital imbeciles and 
idiots grow old soon. Yery many races of men grow old early, like the 
Kalmucs and Hottentots ; but, roughly speaking, in our race one cannot 
call a man old till he is sixty, though I have often met with senile mental 
symptoms between fifty and sixty, and, as we know, atheromatous 
arteries and consequent tissue degenerations are common enough before 
then. But in speaking of senile insanity, I shall include no one under 
sixty years of age. 

It is, of course, a well-known fact that mental disease, speaking gen- 
erally, is a disease of middle and advanced life rather than of youth. Of 
the general population under 20 a very small percentage become insane. 
Only 0.9 per 10,000 of the general population under that age are sent 
to asylums in a year in England and Wales, while 11.4 per 10,000 over 
60 are so sent, or about twelve times the proportion. 

The best foundation for what I have to say of senile insanity will be 
the chief statistical and clinical facts recorded about 203 cases (71 males 
and 132 females) that have been classified under that heading in the nine 
years' admissions to the Royal Edinburgh Asylum, 1874-82. The total 
number of patients admitted in that time was 3145, and they were of all 
classes, from the sons of peers of the realm down to the lowest beggar. 
Of these, 304, or 9.6 per cent., were over 60 years of age. One remem- 
bers this better by thinking that one-tenth of them were over 60. But 
of these 304 cases only 203 were called by me senile insanity. The other 
101 were mostly epileptics, old cases of long-existing mania or dementia, 
or cases of climacteric insanity — that is, old age had acted as a predis- 
posing or exciting cause of the mental disease, and the symptoms were 
more or less characteristic of senility in those 203 cases only. Six and 
a third per cent, of the whole admissions, or one-sixteenth of them, were 
thus cases of senile insanity. It is, therefore, a common, but not the 
most common, form of insanity, as compared with the other clinical 
varieties of mental disease. 

The great predisposing cause of insanity, heredity, appeared to be, 
as I have said, very uncommon. Only 26 of the cases, or 13 per cent., 
were so affected. In estimating the frequency of heredity in mental dis- 



SENILE INSANITY. 397 

ease, one has to add an enormous margin for ignorance and conscious or 
unconscious concealment of facts. In the nine years under review, 723 
of the whole 3145 cases, or 23 per cent., were ascertained to be heredi- 
tary. The senile heredity, therefore, was little more than half the ordi- 
nary average heredity. 

The form assumed by the different cases is a question of great interest. 
I confess I was myself astonished at the immense variety of mental 
symptoms present. Till I had these 203 cases analyzed, I had not fully 
realized either the character or the results of treatment of the disease. 
Looking first at the presence or absence of mental depression or mental 
pain, I find that 69 of these cases, or about a third, were depressed, and 
classified by me as laboring under melancholia. To feel pain, mental or 
bodily, the brain needs to be to a certain extent sensitive and active 
functionally. But the peculiarity of many of the cases of senile insanity 
was, that the mental depression was merely outward in muscular expres- 
sion, not heing felt in any proper subjective sense, and it was certainly 
not remembered. It was, in fact, automatic motor misery, and not con- 
scious, sensitive, mental pain. One of the cases lately under my care 
illustrates this very well : L. A., aet. 83 at death. His mental power 
had been failing for three or four years. At first there were failure of 
memory, irritability, exaggerated opinions of himself, morbid suspicions, 
sleeplessness, restlessness, and lack of self-control. These symptoms 
gradually got worse, until his memory was quite gone, and he did not 
know his age, or his wife, or his home. Yet his appetite was good, his 
health in some respects better than it had been before, for a gouty ten- 
dency had disappeared. He looked fresh and well, and his muscular 
strength in spurts was very great indeed. He had, a year or so after the 
beginning of the attack, a sort of hemiplegic attack, transient and slight ; 
and ever since it began, and going along with it as one of the symptoms 
of the disease, there was a slight indistinctness of speech, a want of motor 
activity and perfect coordination in the articulatory muscles, a change in 
the tone of the voice in the direction of feebleness, a difficulty in finding- 
words, a tendency to stop in the middle of sentences, an omission of 
words, especially nouns — in fact, the typical senile speech, with its mix- 
ture of aphasic, amnesic, and paretic symptoms. The senile speech I 
look on as just as characteristic as the aphasic, the general paralytic, or 
the hemiplegic speech, and just as illustrative of brain function. He 
had all the signs of advanced atheroma of his vessels. 

About the middle period of his disease, his memory was quite gone for 
recent things, and you could scarcely engage his attention for more than 
a few seconds on any one subject. At times, in fact, mostly, he showed 
a kind of happy negative contentment. If you could get the thread of 
his old life, he would tell old stories, make speeches, and look as wise as 
possible ; but all this time he did not know who you were, or where he 
was, or the day of the week, or the month, or the year, or what he had 
for dinner. Then suddenly, without any outward cause, a chanoo would 
come over him. He would look most miserable, would moan, and groan, 
and weep (tearlcssly), wring his hands, uttering disjointed exclamations 
of sorrow ; but he could not tell you what grieved him, and in a minute 
or two he might be quite cheerful, and he remembered nothing about it. 



398 SENILE INSANITY. 

denying that he was at all dull or ever had been so. Or he would at 
times suddenly, causelessly, become intensely suicidal, trying to strangle 
himself, running his head against the w^all, or clutching his throat with 
his hands. In that condition you could not rouse his attention. He was, 
in fact, practically unconscious, and when controlled or prevented carry- 
ing out his suicidal attempts, he would struggle and resist desperately 
and unreasoningly. At other times he would have sudden homicidal 
attacks. But in half an hour after all this he would be calm, chatty, 
and utterly oblivious of everything that had occurred. The w^hole thing, 
in fact, the pain, the suicidal and the homicidal impulses, were so many 
automatic acts unaccompanied by motive, reason, or remembrance, and 
were the mere motor signs of some organic discomfort. All his worst 
symptoms used to come on at night, when he would become noisy, rest- 
less, shouting, resisting, and quite unmanageable, alarming the household 
and neighborhood. The continuance of those symptoms wore out every- 
one connected wdth him. Of all forms of insanity, the senile is apt to 
become most aggravated at night. It might be supposed that there could 
scarcely be any conceivable circumstances under which a man of that age, 
with means enough to procure proper attendance, would have to be sent 
from his own home. Yet those circumstances occurred. Home treat- 
ment was a failure, and could not be any longer persisted in. Certainly 
he did better in a villa of the asylum, with plenty of fresh air and regu- 
lated exercise "little and often," regularity of life, lots of milk and eggs, 
and digestible, plain food, and good skilled attendance ; getting fat and 
sleeping far better. But, of course, he slowly got more enfeebled in 
mind ; his suicidal impulses became less intense, his noise at night less, 
and his resistiveness more controllable, but his motor restlessness re- 
mained. All his symptoms were irregularly periodic and remissional. 
For months he would be quiet, and then would have a few weeks of 
motor excitement, and night noise, and impulsiveness. What is the 
cause of these aggravations in senile cases — and they are very common, 
almost universal ? I really do not know. I presume one must look on 
them as being partly mere action and reaction, activity and exhaustion 
simply. In such a case we can have no reproductive periodicity to deal 
with. He died of simple senile exhaustion, but with resistance to feed- 
ing, restlessness, and noise to some extent, up till three days of his death. 
It is very difficult to know how to classify such a case symptomatologi- 
cally. There was undoubted dementia, and there was maniacal excite- 
ment. There were all the outward signs of suicidal melancholia, and the 
symptoms of true impulsive insanity. I adopt the rule, that wherever 
there is marked mental pain, or the outward signs of it, the case is put 
down as melancholia in our books. L. A.'s case is a typical example of 
pure senile insanity of the melancholic type. But many of the cases of 
senile insanity classified symptomatologically as melancholia were entirely 
different from this case. Several of them were cases of simple melan- 
cholia that proved to be transient, its only special senile character being 
that it occurred in old people, was accompanied by more loss of memory 
than usual, and the recovery it ended in had somewhat of normal senility 
in it. Several of the cases were caused proximately by bodily diseases 
that exhausted the strength or lessened the blood-corpuscles, or by moral 



1 



SENILE INSANITY. 399 

causes. It is quite comnion in my experience, and, I believe, in that of 
all medical practitioners, to find certain old persons much depressed in 
mind by any bodily disease. Notably I have seen this happen in the 
course of bronchitic or heart troubles, where the blood was not aerated. 
In fact, given a senile brain, atheromatous arteries, and non-aerated 
blood, and we are pretty certain to have the mental functions of the brain 
affected. I am in the habit of speaking loosely of "cyanotic delirium " 
and " cyanotic insanity" from the non-oxygenation of the blood in bron- 
chitic and cardiac disease. Others of my cases of senile melancholia had 
fixed melancholic delusions. Intense suicidal feelings were rare, and 
very determined attempts still more rare, but we cannot depend on this 
rule in all cases. Of the sixty-seven melancholic cases, seventeen were 
acute in symptoms, and fifty were mild. 

Of the melancholic patients, thirty per cent, were discharged as tech- 
nically " recovered "—that is, in all of them their worst mental symp- 
toms disappeared, they passing into normal senility. In many cases they 
became quite well in an absolute sense. In the melancholic patients, 
speaking generally, the recoveries were apt to be better than in any other 
class of senile cases, as in the following example : 

L. B., set. 77, a man of reserved disposition, steady and temperate 
habits. There was no known heredity to insanity. He had never shown 
any disposition to depression of rnind before. He had done his modest 
work in life well ; had brought up a healthy and well-doing family, and 
was an intelligent and religious man. His business was not prospering, 
and he became depressed and restless. He imagined he was eternally 
lost, that the diminution of his business was a direct judgment of God 
for his sins. This in religious people, and in irreligious ones, too, is a 
very common melancholic delusion, and the public will always have it 
that any kind of religious delusion or "religious insanity " is a very bad 
symptom in every case, and necessarily incurable. Now there is only a 
little truth in this. The idea has arisen, no doubt, from the fact that the 
cases with fixed delusions of a religious kind — the prophets of the Lord, 
the sons of God, the possessed with a devil — are usually incurable, and 
such cases make a very strong impression on the public mind. L. B. 
gradually got worse, and talked of committing suicide by throwing him- 
self over the North Bridge — a fearfully suggestive and then low-parapeted 
place. After eighteen months of treatment at home, he got so ill that he 
was sent to the asylum. On admission he was depressed, restless, un- 
settled, and talkative, with religious delusions. He looked an old man, 
with atheromatous arteries, and there were senile cataract and marked 
heart disease ; but his appetite was good, and his general nutrition and 
strength very fair for his age. He did not sleep well at first. He was 
ordered Parrish's syrup of the phosphates, cod-liver oil, with milk diet, 
and fresh air when the weather was suitable. There was a hypochon- 
driacal character about his mental depression all the time. In about two 
months he had strengthened and improved. He became more obviously 
concerned about the state of his bowels than that of his soul. He was 
one of the melancliolics — a numerous array — who heard "the clock 
strike every hour of the night." In about nine months he was alniost 
free from the mental depression, and his memory had got bettor, while 



400 SENILE INSANITY. 

he looked quite ruddy and hale. In a year he was really quite well, and 
was sent to his home just as cheerful and more active than the average 
man of seventy-eight. He came out to see us for three years after, in no 
respect the worse, mentally or physically, for his interlude of two and a 
half years of senile depression and insanity, and he died peacefully at 
home in his eighty-fourth year. 

Turning now to the cases that showed no melancholic symptoms, or, 
at all events, where such symptoms were not long continued or prevailing. 
There were 134 of these, all of whom having some sort of motor excite- 
ment, they were put down at first as cases of "mania." As I do not 
recognize "dementia" to be curable when used in a correct sense, I 
scarcely ever at first diagnose any recent case as such, no matter what 
the symptoms are at the time. To my mind, a patient is only proved to 
labor under dementia when he is proved by lapse of time to be incurable, 
and has the symptoms of mental enfeeblement as well. Many of these 
134 senile cases were really cases of dementia, but I put them down as 
mania at first, because their enfeeblement of mind had not been proved 
to be incurable, and because they had more or less motor excitement. In 
only 19 of these was the excitement so intense as to be classified as acute 
mania. The mental symptoms in these 134 cases, like those of the 
melancholy cases, were very difierent in kind and degree, duration and 
result. Some were short sharp brain-storms preceding death, outbursts 
of delirious excitement accompanying the break-up of the organism. 
Instead of a long and gradually progressive failure of convolutional func- 
tion, in such cases it ended in a quick and tumultuous fashion. Instead 
of mere loss of power from innate trophic failure and want of blood, in 
such cases there is a vaso-motor paralysis and a development of irregular 
cellular energy, expressed outwardly by constant talking, shouting, inco- 
herence, loss of memory, loss of attention, sleeplessness, and, above all, 
by a constant motor restlessness by night and day, but especially by 
night. This was such a case : L. C, set. 78. He had been pretty well 
up to three months ago, and at that time the excitement and exertion of 
moving from one house into another seemed to exhaust him. He first 
became stupid and peculiar, and this come on suddenly, being noticed 
particularly one morning. He gradually became excited, incoherent, 
threatening, unmanageable, and his memory was lost, but for ten days 
only, before being sent to the asylum, had he been very excited. The 
whole household and neighbors were disturbed by his noise,, and his 
friends and doctor decided that he must be sent to an asylum. On ad- 
mission, he was weak muscularly, spoke with the voice and articulation 
of a very old man ; he was confused, and his memory was gone. He 
said he was forty, and could not answer almost any question correctly. 
His heart's action was weak, and there were moist rales heard all over 
his chest, but there was no acute disease, his temperature being 98.4°, 
and his pulse 80. The left side of his face was slightly paralyzed, and 
his pupils unequal. There was no paralysis of arm or legs. He did 
not sleep, and was noisy and excited all night. There was much diffi- 
culty in making him take his food, too. His bronchitis was bad, and his 
cough very troublesome. Within forty-eight hours after admission, he 
got pale and weak, his breathing became labored, and he died suddenly 



SENILE INSANITY. 401 

that day. There was no post-mortem examination. His relatives natu- 
rally were very sorry they sent him to the asylum, and were inclined to 
blame the doctor who recommended it. No doubt, if the result could 
have been foreseen, no one would have recommended his leaving home, 
but I do not think there were any definite symptoms present pointing to 
the result. When consulted about cases of senile insanity, I always have 
before my mind the question, "Are those mental symptoms not the mere 
forerunner and accompaniment of a general break-up ?" And to answer 
that question it is desirable to go into the condition of the brain, the 
heart, the lungs, the kidneys, and the general strength very carefully. I 
am always suspicious of sudden oncomings of mania in old people being 
of this character. 

The following case was typical in its inception, symptoms, incidents, 
duration, and pathology : L. D., aet. 78. Had been hard-working, and 
as drunken as his limited means would allow. Senile insanity is often 
the penalty for an excessive use of alcohol in earlier life. About nine 
months ago he got a fall down stairs, and has not been so strong or well 
since. About six months ago, his memory began to fail, then he became 
stupid and confused, then suspicious, then restless, then unmanageable, 
then violent to his wife, and was then sent to the asylum as a pauper 
patient. On admission, he was confused, slightly excited, very restless, 
his memory gone, his general condition weak, his senses blunted, his 
speech senile, his pupils irregular in outline, his tongue tremulous, his 
pulse 90, w^eak and intermittent, his temperature 98.2°, his lungs and 
other organs healthy, and his appetite good. He was well fed and nursed 
in our hospital ward, but, though he gained in flesh, he did not improve. 
He was restless, especially at night, became gradually dirty in his habits, 
moved about in a purposeless way all the time. The motor restlessness 
of a senile case is an extraordinary vital phenomenon. He never sits 
down, seldom sleeps, he shouts, and walks about his room all night, and 
yet never tires. I found that this symptom existed in sixty per cent, of 
all the cases. Whence the source of all this most unnatural muscular 
energy ? It exhausts his small stock of real strength, though he does 
not feel it. It is the antipodes of the quietude and disinclination for 
exertion of the normal old man. 

About three months after admission, as he was aimlessly carrying a 
chair in the day-room, he slipped, falling down, and breaking his right 
femur at the neck inside the capsule, an accident always liable to happen 
to a senile patient. He got on pretty well, being left in bed and nursed 
and cared for as well as was possible. In about two months the restless- 
ness came on again, and in trying to rise he hurt his leg again. In about 
a month he died of exhaustion, having been ill for ten months, there 
being much difficulty in preventing the formation of bed-sores before 
death. The difficulty of managing such cases satisfactorily in an asylum 
or out of it is extreme. They are very restless, always meddling with 
something or somebody, very obstinate, entirely forgetful and purposeless. 
They are constantly making their water on the floor, in a corner of the 
room, or in another patient's hat. They need bathing often. Their 
bowels are cither too costive or too loose. They are liable to retention of 
urine from enlarged prostates and bladder paralysis. They either eat too 

26 



402 SENILE INSANITY. 

much or will not eat at all. A slight fall breaks their bones. To lie 
near other maniacal or irritable patients is out of the question, for they are 
sure to get hurt. For them one requires to use the best attendants, the 
best single rooms at night, and the best parts of a fully-equipped hospital 
ward ; and all this needs to be done by nurse and doctor under the 
depressing feeling that it is of no use in the long run towards the cure of 
the patient. 

On a post-mortem examination of L. D's. case the pia mater and 
arachnoid were found thick and opaque, but stripping freely off the con- 
volutions, Avhich were over the vertex of the brain atrophied and covered 
with an opaque compensatory fluid. On section the gray substance 
of the convolutions was irregularly thinned and soft in texture, the peri- 
vascular canals being enormously enlarged. In the extra-ventricular 
nucleus of the left corpus striatum there was a recent hemorrhage the size 
of a pea, and in the right optic thalamus one of the same size of older 
date. There was a small softening from embolism or thrombosis in 
another part of the thalamus. The lining membranes of all the ventri- 
cles were granular, and the lateral ventricles were enlarged from intersti- 
tial brain atrophy. All the brain arteries were atheromatous in patches, 
causing diminution of their lumen at these points. There was dilatation 
of both ventricles ; aorta was very atheromatous, lungs were oedematous, 
liver slightly nutmeggy, right kidney disorganized and the seat of an 
extravasation of blood. On microscopic examination the large cells in 
the inner layers of the convolutions were found in the degenerated 
atrophied state, with their processes gone, as represented in Dr. Major's 
plate (Plate VIII. Fig. 4).^ There was much debris round the vessels in 
the perivascular canals. In some few of the cases the pathological 
appearances are indicative of a much more intensely disturbed state of the 
convolutions during life. For instance, in a case I examined, L. E., 
8et. 76, who had been ill for fifteen months, the last three of which were 
spent in the asylum, and who had, in addition to the symptoms of the last 
case, great violence at times, wanting to get out of his house, w^hicli he 
maintained was not his own, an epileptiform attack, a very indistinct, 
thick, scarcely intelligible articulation, all his symptoms remissional, more 
emotionalism, and a temperature of from 99° to 100°, we found after death 
great adherence of the dura mater to the skull-cap, and a very dark- 
colored false membrane, varying from a quarter of an inch in thickness, 
covering the whole of the vertex, and descending down and covering the 
base in a thin layer. In this membrane there were several pure blood- 
coagula from the size of a pea up to that of a small walnut. The pia 
mater was not adherent (though in two or three senile cases I have found 
it to be so), the ventricles were granulated, and there was much general 
atrophy. There was hypertrophy of the muscular substance of the heart 
and aortic incompetence. 

The following is a case of transient senile mania ending in recovery : 
L. F., agt. 63, a man of a cheerful disposition and somewhat intemperate 
habits. By the way, liquor undoubtedly affects an old man far more than 
a young one in the direction of producing insanity as well as less marked 

^ "West Biding Medical Eeports, vol. v. p. 161. 



SENILE INSANITY. 403 

neuroses. It tends more towards tissue degeneration at advanced ages, 
and the nerve tissue suffers most in neurotic subjects. There was some 
insanity in the family, but he came of an otherwise sound, long-lived stock. 
Three months ago he had an old ulcerated leg healed up. Had a perineal 
abscess a fortnight ago, which was opened, and since then has been 
affected in mind. The attack is recent, and came on suddenly. He 
began to take fancies that he was rich, got excited, and had a great crav- 
ing for drink, which he indulged, and got much worse after it. On 
admission he was greatly exalted, saying he was possessed of all knowledge, 
power, and wealth. He was excited, shouting and crying, said he w^as 
the "Messiah God," that he had millions of money. He did not sleep, 
and his appetite was poor. He was dirty in his habits, and constantly 
restless. He was fed well, and got tonics, chiefly iron and quinine. 
Within a month w^as quiet and almost rational and free from delusions. 
In about three weeks more he began to suffer from headaches, and soon 
became melancholic and morbidly anxious about his health. After having 
begun to sleep well, he again lost the power of sleeping in this melan- 
cholic stage. In about another month he gradually got out of the 
depression, and passed into a quietly contented, rational sane senility. 
He went home, and ended his days in peace after some years. He 
entered on the attack a middle-aged-looking man ; he came out of it 
visibly an old man in body and miild, but in no respect a dotard or unfit 
to manage his affairs in a quiet way. This was a case of senility ushered 
in by a brain-storm. Mentally he at first resembled a typical general 
paralytic. 

Looking at senile insanity broadly, there is no doubt that its pure type 
is to be found in the restless, sleepless dotard, without memory, without 
true affectiveness (at the beginning of the disease there are often affective 
hyperaesthesia and uncontrollable emotionalism), without crisp, articulate 
speech — second childhood in an unmanageable form, in fact. That is the 
true senile dementia, out of Avhich there can be no issue but death. Of 
this class of case there were in a typical form sixty-two cases of the two 
hundred and three, or thirty per cent. That statistical result was a 
surprise to me. I had expected more of that type. Some of the others 
seemed to be of that character at one period of the attack, but they came 
back to something like normal mild senility. As might have been 
expected on physiological grounds, the typical cases of senile dementia 
were found in greatest numbers at the more advanced ages, but from 
sixty up to seventy-five there was no regular increase in their number. 
Under seventy -five there were only eighteen per cent, of typical dotards ; 
over seventy-five there were over fifty per cent. 

Some of the cases were quite strong in body, and, beyond some arterial 
degeneration, showed no signs of bodily disease, and their mental condi- 
tion was a cheerful forgetful enfeeblement. I have one such man of 
seventy, as good a garden worker as we have, who sleeps well and eats 
well, but cannot tell you the day of the week, calls me an old friend, and 
has no idea Avhere he is. Another marked type is that of pure senile 
elevation, with delusions of great possessions and power, as in L. F"s. case. 
Such delusions, existing along with mild maniacal exaltation and the 
senile articulation, are very like cases of general paralysis. They are 



404 SENILE INSANITY. 

constantly diagnosed as such, in my experience. But general paralysis 
scarcely ever appears after sixty, and never after sixty -five. A close study 
of the speech, too, will usually determine the difference. There is not the 
true general paralytic fibrillar trembling, or the spasmodic convulsions of 
the smaller facial and labial muscles. Quite a number of cases were 
of that type in the early period of their disease. One such case of sixty- 
five, A. H., had millions of money ; the asylum belonged to him ; he 
would give you a thousand pounds for the asking ; he was happy as a 
king, and he was constantly restless, pulling off his buttons and taking off 
his clothes. His speech was thick, hesitating, and wanting in crispness 
of tone. He gradually became hemiplegic, and died in about two years, 
a dotard. A large embolic softening was found in his corpus striatum, as 
well as several smaller softenings in the convolutions of the motor area 
of the cortex. 

Many senile cases have hallucinations of hearing. I have now two 
old women who hold regular conversations with people in the ceiling and 
in the next room. Some of the men develop a morbid eroticism and a 
physiological immorality. Many a marriage I have known to be made 
by commencing senile dements. I had one patient of eighty, L. G., 
whose conduct towards his female nurses was so bad that few respectable 
women could be got to look after him, and yet he was of the melancholic 
type, "just going to die" every day. Masturbation is not unknown in 
senile insanity. The hypochondriacal mental symptoms that are certainly 
one of the most characteristic features of the cases of climacteric insanity 
are sometimes seen in senile cases. In most cases there are morbid sus- 
picions at the beginning. I had an old lady patient who dismissed her 
old faithful servant two or three times a week for stealing her clothes. I 
saw one lately who believes that her neighbors come into her house and 
plot to rob her of her money. The characteristic of the senile suspicions 
is that they refer to things that are possible to happen, to stealing of 
clothes or money, to faithlessness on the part of near relations, etc., and 
do not refer to the impossible things that cases of real monomania of 
suspicion believe, to electric and mesmeric agencies, or to elaborate social 
plots. The senile cases are constantly changing in their suspicions and 
fancies, too ; one day it is one thing, another day another. 

In a few of the cases food is refused — a very troublesome and a very 
grave symptom. To feed an old man or woman by the nose- or stomach- 
tube does not seem, somehow, to be followed by such good results as the 
forcible feeding of younger patients. The mucous membrane of the mouth 
and fauces is apt to get dry, and diarrhoea to set in. In two or three 
cases hoematoma auris developed during the acutely maniacal stage, this 
no- doubt indicating marked vascular disease and trophic disturbance. 

The ages of the cases are best seen by a glance at the table below.^ 



'Age. 


Total Nos. 


Recovered. 


60 to 65 


62 


24 


65 " 70 


63 


21 


70 " 75 


40 


15 


75 «' 80 


30 


9 


80 " 85 


3 


1 


65 " 90 


5 


2 



203 72 



SENILE INSANITY. 405 

Taking the whole number of cases (203), over 60 per cent, of them were 
between 60 and 70, 35 per cent, were between 70 and 80, and about 4 
per cent, over 80. That is not far from the proportion at those ages in 
the general population over 60. The chief difference is that the propor- 
tion of insane persons between 70 and 80 is greater, while the proportion 
of the sane over 80 is double that of the insane. 

One of the most interesting and important of the results I obtained 
from an analysis of those 203 senile cases was a clearer idea than I had 
before of the course of such cases, their duration, and the results of treat- 
ment. The general result was that seventy-two of the cases, that is, 35 
per cent, of them, were discharged from the asylum recovered ; and sixty- 
nine cases, that is, 33 per cent., have died ; while thirty- three cases were 
discharged more or less improved or not at all improved, leaving twenty- 
nine cases under treatment. The striking fact is the number of recoveries. 
I must explain that the "recovery" from any form of senile insanity need 
not necessarily be, and is not, as a matter of fact, an absolute restoration 
to vigor of mind. Some such complete recoveries there were, men who 
went out and earned their own livelihood, women who went out and 
governed their households. But such cases were usually the short 
attacks of exaltation or depression that I have referred to. They mostly 
occurred between the ages of 60 and 75, though they were not absolutely 
unknown after. At least one-half of the recoveries, perhaps rather more, 
were returns to or gradual passings into comfortable, manageable, normal 
senility. That is all that can be expected in a case with the typical 
characters of senile insanity. It is all I ever lead the relations to expect 
will occur. But it is a most happy change from senile mania. To have 
an aged father or mother pass out of such a condition, and become fit to 
go home and be lovingly cared for till death takes place, is an occurrence 
for which most persons of proper feeling will be profoundly grateful. 
When such a return to normal senility occurs, there is usually little 
tendency for the excitement to return under proper care and feeding. 

The recovery rate in each quinquenniad from 60 to 75 was about the 
same, and the rate in that whole period of fifteen years was 36 per cent., 
or 60 cases out of 165. The numbers in each of the next quinquenniads 
were too small to give results worth generalizing on, but the total number 
of recoveries in the thirty-eight cases over the age of 75 was twelve, or at 
the rate of 32 per cent. This last was one of the results that surprised 
me, I confess. 

The recoveries took place in about the usual time that recoveries from 
other forms of insanity take place. About one-half (47 per cent.) of 
them were discharged recovered within three months of residence, and 
over three-fourths (79 per cent.) of them within six months. In foct, 
rather a larger number recovered within six months than the average 
recoveries in an asylum. 

Sixty-nine of the 203 cases have died up to this time. There is much 
risk of them dying within the first month ; this, of course, meaning that 
in a considerable number of cases the mental disease is of the nature of 
an ante-mortem delirium, like L. C.'s case I have related. Seven per 
cent, of the cases died within the first month, making about 20 per cent, 
of the whole of the deaths. Far more died in the first than iu any sub- 



406 SENILE INSANITY. 

sequent month. More than half the deaths occurred within the first six 
months of residence, that being a considerably earlier period of death 
than occurs in most other forms of insanity. 

Pathology of Senile Insanity. — The pathology of the disease is 
interesting because it has some approach to definiteness. It is, next to 
general paralysis, the form of mental disease in which the most distinct 
pathological appearances are found in the brain. Out of the ninety-two 
deaths we were allowed to have post-mortem examinations in fifty-two 
cases. I often find it unusually difficult to obtain permission for post- 
mortem examinations in senile cases. An exhaustive analysis of the 
pathological appearances found in these fifty-two cases would be far too 
tedious to attempt. Many of the cases would need a special description 
to do them justice. All I shall attempt is a summary of the chief ap- 
pearances. The most common of all the lesions found in the brain itself 
was that form of combined cerebro-vascular disease, commonly called 
softening of the brain. This occurred in a marked form in twenty-two 
cases, or forty-two per cent, of the whole. I need hardly say that I use 
the term in the proper sense of a ramollissemeyit^ a localized necrosis, 
partial or entire, of a portion of brain tissue, resulting in most cases from 
a deprivation of blood through embolism or thrombosis of the arterial 
branches supplying it. In every case of softening there was marked 
vascular disease, and in many cases the obstructed vessel that had 
formerly supplied the starved portion of brain could be demonstrated. 
Commonly the form of vascular disease was atheroma in an advanced 
form, sometimes aneurisms, large and small, sometimes inflammatory 
general thickening of the coats of the vessels. The softenings were com- 
monly localized and seldom very extensive, in this diifering markedly 
from the softening found in the brains of younger insane persons. They 
were found everywhere, but the most common sites were the great basal 
ganglia, notably the corpus striatum, and the convolutions of the vertex 
and lateral portions of the anterior and middle lobes. The appearances 
of the softenings were very different in different cases, according to their 
duration and the sudden or gradual onset of the lesion. When a twig of 
a cerebral artery is suddenly obstructed by an embolic plug, most of the 
tissue supplied by it dies at once, a sort of inflammatory process (the 
''red softening" of the older pathologists) taking place for a few days 
first. Then it liquefies from the centre outwards, appearing as the typical 
"white softening," the process usually tending to spread into the sound 
tissue, but sometimes, if the dead portion is very small, the debris gets 
partly absorbed and the tissue round it sacculates, or, in still rarer 
instances, shrinks together, forming a condensed cicatrix-looking spot. 
But no doubt the common thing is slow progression of the softening, in 
accordance with that fatal law of progressive nerve-tissue degeneration 
first described by Waller in the peripheral nerves, and which has since 
been found to exist in so many nervous diseases. In senile cases the 
softening process is commonly gradual through the slow starvation of an 
area of brain tissue from a gradual atheromatous diminution of the lumen 
of its supplying vessel. I did not at one time believe in a non-syphilitic 
senile arteritis afi"ecting all the coats of the vessels. Now I do, for I have 
seen it. And I know of no test to distinguish such arterial disease from 



SENILE INSANITY. 407 

the more common syphilitic arteritis. In that case there is no preliminary 
red softening, but a slow absorption of the nervine tissue, a corresponding 
compensatory development of the less vitalized neuroglia and packing and 
retaining tissues generally, giving the appearance at first of a spongy gray 
area, and going on to its complete atrophy and disappearance. The ap- 
pearance caused by the sudden and the gradual starvation process differs 
much in the convolutions and the white substance. The former having 
about five times the blood-supply of the latter, it is far more apt to be 
filled with hemorrhagic debris in the sudden cases, and to have a gray, 
dirty, gelatinous look in the gradual cases. The convolutions or parts of 
convolutions affected look wasted, the pia mater comes off readily, and to 
the touch their resistance is very soft. It is difficult even to harden them 
in spirit. The chief blood-supply of the convolutions being derived from 
small arterial twigs from the pia mater, each twig not anastomosing much 
with the others, but nourishing a small convolutional area of its own, if 
one of these is obstructed its area dies and softens, slowly or quickly, 
according to the kind of obstruction. But, as Duret and Heubner show, 
the convolutions have a second blood-supply from within. We do not 
find the complete necrosis of tissue in the gray that is found in the white 
substance. The former always retains some vitality, and seldom becomes 
a liquid pulp, or altogether disappears, like the white substance, from this 
cause. 

The next notable appearance observed was marked atrophy of the 
Avhole brain, or of considerable portions of its convolutional surface. 
This existed, alone or in conjunction with other lesions, in so marked a 
degree as to be put down as one of the direct causes of death in twelve 
cases, and in a lesser degree in most of the others. No doubt this atrophy 
is partly the same process as softening, only the starvation process is 
slower still, and is partly owing, not to a diminished blood-pabulum 
merely, but to an innate lack of trophic energy in the neurine elements. 
It manifests itself in brain sections by much enlarged perivascular canals 
and dilated ventricles. The curious way in which the cerebral envelopes 
and packing elements seem to make an effort to expand and compensate 
in bulk for the shrinking brain is, I suppose, partly connected with the 
physical conditions of the closed box within the cranium, inaccessible to 
the atmospheric pressure except through the bloodvessel openings and 
the foramen magnum; and partly owing, no doubt, to the congestions of 
the whole of the tissues supplied by the carotid arteries and their branches 
that accompany the paroxysms of maniacal excitement. From whatever 
cause, when the brain is most atrophied we are most apt to have thicken- 
ings of the skull-cap, often taking the form of successive layerings of 
bone over the inner table where it covers the vertex, and especially over 
the anterior lobes, where the atrophy is usually most marked. The dura 
mater is commonly thickened, and usually adheres pretty strongly to the 
skull-cap. The arachnoid is thickened, the pia mater thick and fibrous, 
and the cerebro-spinal fluid superabundant, milky, and full of microscopic 
debris. 

There were recent apoplexies of such a size as to be seen by the naked 
eye in only five cases. Microscopic apoplexies within the pia mater, in 
the tissues and round the softenings, and in the perivascular canals, are 



408 SENILE INSANITY. 

much more frequent. In fact, there are few cases of senile maniacal 
excitement in which such apoplexies cannot be found in these positions. 
But among all those cases of softening it seems marvellous that there 
were not more cases of apoplexy. Given vessels with weak, diseased, 
and inelastic coats, given atrophy and softening of the brain, the place of 
the solid tissue being taken by mere liquids and spots of softening, and 
add to these maniacal attacks implying intense vascular congestion, one 
would think that large apoplexies must occur in every case from the want 
of support to the diseased vessels. Yet we have seen this was seldom the 
case. The existence of small apoplexies probably explains the occurrence 
of transient attacks of hemiplegia, as in a very interesting senile case in 
this asylum reported by Dr. J. J. Brown,^ in which the whole of the pia 
mater was full of miliary aneurisms, and most of the convolutions filled 
with pin-point apoplexies. Such cases, as well as the cases with limited 
softenings, bring senile insanity into close relationship pathologically with 
paralytic insanity, with which it has many common features. They are 
the two clinical forms of ir>sanity most allied. Senile insanity often be- 
comes paralytic insanity. Paralytic insanity always has many of the 
mental symptoms of senile insanity. 

There was distinct meningitis in three cases, one of which was the case 
of L. E., with "pachymeningitis hsemorrhagica externa," referred to on 
page 402. Of the other organs of the body, the heart was found most 
frequently afiected, there being marked cardiac disease in ten cases. The 
lungs came next, with bronchitis and broncho-pneumonia in nine cases ; 
and next the kidneys in two cases. In many of the patients several of 
the above morbid conditions were combined. 

With regard to the microscopic appearances in senile brains, I must 
refer to the careful and correct descriptions and drawings of Dr. Major.^ 
We have all been able to confirm those observations, and perhaps to see 
some speajial points in addition, but have not been able to add much to 
them. The various stages in the degeneration of the large cells, the 
atrophy of the smaller cells and nuclei, the enlargement of the vascular 
canals, and the debris of granules and hasmatin crystals, are all well 
described by Dr. Major. I have met with such general atrophy, as is 
represented in Plate YIIL Fig. 3, in several cases in which the nerve-cells 
and fibres were gradually disappearing, leaving only an irregular loose 
reticulation of cell-walls, neuroglia, and atrophied vessels. 

The weak point in the pathology of senile insanity is that we have no 
means of comparing those lesions and changes I have described with the 
appearances of the brains of old persons who were not insane. Beyond 
a doubt, some of them, both naked-eye and microscopic, are present in 
persons whose mental condition never got beyond normal senility ; but 
there is less doubt that in the brains of fifty-two persons from the average 
population over sixty, there would not have been found so many soften- 
ings and atrophies, etc. What we have to ask ourselves, in order to form 
anything like a proper conception of these cases of senile insanity, is, 
what was the relationship between the purely dynamical phenomena of 

^ Journal of Mental Science, July, 1874. 

2 West Eiding Eeports, vol. ix. p. 223 ; and Ibid., vol. v. p. 161. 



SENILE INSANITY. 409 

morbid mental exaltation or depression, loss of memory, and constant 
purposeless motor excitement, during life, and the atrophied convolutions, 
the degenerated cells, the diseased vascular system, and the starved areas 
of brain found after death ? Did these pathological changes, when they 
advanced to a certain point, simply allow old hereditary convolutional 
weaknesses to come out that had been so slight that by nothing but slow 
death of brain tissue could they have become actualities instead of mere 
potentialities ? Or had the advancing brain degeneration simply weak- 
ened and destroyed all the higher inhibitory faculties and "centres" in 
the brain? Is the constant motor restlessness referable to the progress 
of the manifest changes in the larger "motor" cells of the convolutions? 
Is the loss of memory a mere paralysis of the power of attention and 
mental concentration on sense impressions — a result of the loss of inhibi- 
tory power, in fact ? Or is it, in addition, an absolute paralysis of recep- 
tive capacity on the part of the cells in the convolutions, the impressions 
from the senses being "writ in water"? Or do the impressions not 
reach the convolutions through degeneration of the white conducting 
fibres ? As to the memory of old events, which is the last to go, is that 
just the result of destruction and atrophy of the cells as organized activ- 
ities ? What light does the whole known pathology throw on the constant 
connection of the mental and motor symptoms ? It seems to me that 
that connection in senile insanity is another proof of the motor functions 
of some of the brain convolutions. 

How can senile insanity best be treated and managed ? I can only lay 
down the principles that I have found useful, and can scarcely enter into 
the details of individual cases or requirements. The thing of first 
importance is undoubtedly to get a good nurse — a responsible, skilled, 
patient, experienced person. Women make by far the best nurses for old 
people of either sex, but for male patients they are sometimes not 
physically strong enough. After a good nurse (and a daughter or rela- 
tive will sometimes make the best of all) comes the routine of management, 
diet, exercise, and regimen. Excitement, and new things or ways, or 
places or persons, should be avoided. Old people take best with what 
they have been accustomed to. Warmth by day and night is most 
important, combined with airiness of the apartments. The clothing 
should be warm by night as well as by day. Cold aggravates excitement 
and causes dirty habits. The night management is the most important 
and the most troublesome. It is better not to attempt to keep the 
patients in bed all the time if they will not stay there quietly. Struggling 
with them causes irritation and resistance. A suite of airy, not over- 
furnished apartments down stairs are the best. As to exercise in the 
fresh air, it is most important. It makes all the diiference between being 
able to manage a case at home at all or to manage it well in an asvlum. 
It should not be given up to the point of exhaustion, like exercise 
in young acutely maniacal cases. The walks should be short and often : 
and, when the weather admits, sitting in the open air should be practised. 
Senile patients have a provoking habit of sleeping during the day and 
waking at night. Better sleep by day than not at all. The diet is also 
most important. I find the first food of man to be the best at the oppo- 
site end of life. There is nothing like milk, given warm and in small 



410 SENILE INSANITY. 

quantities at a time, and often. Fatten your patient and you will improve 
him in mind. Too much flesh and beef-tea are often too stimulatincr and 
indigestible ; cod-liver oil often works wonders, and so does maltine. 
Fresh vegetables, or their juice in soups, should always be given. All 
the solid food should be minced or pounded for a large number of the 
cases. 

Sometimes it is necessary to fit up a special room in a private house for 
night use, without furniture, warmed, and that can be cleansed daily. 
Night-feeding as well as day-feeding is often needed. Often a big 
stomachful of hot porridge or bread and milk will give a night's sleep far 
better than a hypnotic medicine. 

The purely medical treatment is, in senile insanity, the least important, 
but we can do something in that way. My experience of opium is 
unfavorable as a sedative. It diminishes the appetite, and often kills the 
patient. But by means of mild doses of the bromides, with or without 
small doses of cannabis Indica, used occasionally as required, we can tide 
over bad nights comfortably. Tonics are useful, and iron and the phos- 
phates often w^ork wonders. Alcoholic stimulants are often useful, but 
not so often as is commonly supposed. The bowels should be regulated 
by the simplest laxatives, some treacle or syrup given with the evening 
meal of porridge being often all that is needed. 

The great aim, in most patients, is to get into comfortable normal 
senility as soon and quietly as possible. In some the restlessness and 
noise are so pathological that nothing seems to have any effect in con- 
trolling or abating them. The patient and his brain simply wear them- 
selves out, and everyone about him is thankful when all is over without 
accident. Few questions are so difficult to determine as the one of send- 
ing a very old person to an asylum or not. The feelings of everyone go 
against it if there are a good home, dutiful relatives, and sufficient means. 
The best way is to try all other means first. In good asylums we give 
the poor suffering from senile insanity a sort of treatment that the 
richest often cannot get at home for any price, and in many instances 
with remarkable success. If, therefore, there are poverty and no conveni- 
ences for treatment, one cannot hesitate about the course to adopt. 

I am well aware of the imperfect view of the whole senile condition, 
bodily and mental, that a physician to an asylum is apt to get from 
seeing the very worst cases only. His picture is filled in with very black 
shadows. To keep himself right, he must take all the opportunities he 
has of seeing and studying senility outside of an asylum, which I 
habitually do, trying to look at it with a medico-psychological and patho- 
logical eye. I never see an old man who fails to interest me from that 
point of view. I wish physicians in general practice who have to meet 
the smaller emergencies of senility would put their observations before 
the world more than they do. I find the management of most old cases 
is regarded without much interest. And yet what a field of psychological 
study, to be able to watch the waning minds of strong men and subtile 
women ? 



LECTURE XVIII. 

EARER AND LESS IMPORTANT CLINICAL VARIETIES OF MENTAL 

DISTURBANCE. 

1. ANEMIC INSANITY. 2. DIABETIC INSANITY. 3. INSANITY FROM 
BRIGHT'S disease. 4. INSANITY OF OXALURIA AND PHOSPHATURIA. 
5. THE INSANITY OF CYANOSIS FROM BRONCHITIS, CARDIAC DISEASE, 
AND ASTHMA. 6. METASTATIC INSANITY. 7. POST-FEBRILE IN- 
SANITY. 8. INSANITY FROM DEPRIVATION OF THE SENSES. 9. THE 
INSANITY OF MYXCEDEMA. 10. THE INSANITY OF EXOPHTHALMIC 
GOITRE. 11. THE DELIRIUM OF YOUNG CHILDREN. 12. INSANITY 
OF LEAD-POISONING. 13. POST-CONNUBIAL INSANITY. 14. THE 
PSEUDO-INSANITY OF SOMNAMBULISM. 

In addition to the more common clinical varieties of mental disease, 
there are a great number of others rarer, but of much interest and in- 
structiveness. Most of them are etiological varieties, but there are some 
forms in which the mental affection must be considered an essential part 
of the disease, as in myxoedema. I cannot enter fully into any of these 
forms, but I shall glance at some of them that have come under my own 
observation. 

1. Anaemic Insanity. — There are a few cases of mental disease due 
to anaemia of the brain from starvation, chlorosis, or prolonged indiges- 
tion, or some other causes of anaemia. We had in the Royal Asylum 
fifteen of those out of the 3145 in the nine years 1874-82. Two-thirds 
of these fifteen were cases of melancholia, and the rest acute mania. 
Eighty per cent, of them recovered. This was one of those who did not : 
L. H., set. 29, of a quiet and reserved disposition, and temperate habits. 
No neurotic heredity known. He had had no work and little food for 
some time before coming into the asylum, and had become weak, anaemic, 
and run down. He then got restless, sleepless, and unsettled, and next 
melancholic, attempting to go over a window. Then he became acutely 
maniacal. He was utterly exhausted in strength, though acutely mani- 
acal when he came into the asylum. The maniacal condition alternated 
with depression, fearfulness, fits of weeping, and partial consciousness, 
saying he " did not mean to do any harm." He was fed up, but he 
became demented and incurable very soon. Most of the cases were mild 
melancholia, some of them having an element of stupor, and those nearly 
all recovered within three months under ffood feedino;, fresh air, and 
qumme and u'on. 

2. Diabetic Insanity. — I have met with two cases in which melan- 
cholia was associated with diabetes mellitus. Both were cases of melan- 



412 DIABETIC INSANITY. 

cholia, looked at from a symptomatological point of view. It is much 
the same to the practitioner of medicine how a case is classified, so long 
as the classification sheds new clinical light on its nature and causation. 
The mental condition of diabetic patients has attracted the attention of 
clinicists, but not so much as it deserves. We, whose practice lies chiefly 
in mental diseases, are often accused of seeing nothing but the mental 
symptoms of our cases ; but we have good reason to complain of the way 
in which the mental symptoms of ordinary diseases are overlooked or 
neglected by general physicians. The psychology of most bodily diseases 
has yet to be written, and one has a faint hope that the clinical study of 
mental diseases by students of medicine may so familiarize their minds 
with mental symptoms that they will be more on the alert to look for them 
in their ordinary practice than they would otherwise have been. When 
they are looked for by those who know how to observe and name them, 
they will be found. The whole history of medicine is one long tale of 
finding things when they were looked for. 

The first case was that of L. K., set. 59, a lady who has held an ofii- 
cial position, working hard for many years. Never insane before, and no 
heredity to the neuroses. Her disease showed itself by mental depression, 
irritability, incapacity for work, a lack of interest in anything, and an 
indecision of character quite foreign to her, all these symptoms following 
a carbuncle on the occiput. I was consulted about her, and discovered 
she had diabetes mellitus, which had existed probably for a year before 
the mental symptoms came on. She had no appetite, could not be got 
to take enough food, and what she did take seemed to do her no good. 
She had the usual bodily symptoms of diabetes — thirst, frequent mictu- 
rition, sugar in urine, thinness, and dry skin. On account of the diffi- 
culty of getting her to take enough food, to dress herself, to go out to 
walk, as well as her noise and restlessness at night, she was sent to the 
Royal Asylum about three months after the depression began. The usual 
treatment was adopted for the diabetes, but with no avail. Her mental 
energy got enfeebled, until she was entirely languid, with no volitional 
power. She had the delusion that she was ruined, and could not pay her 
debts. The only thing she did was to keep up a continual wail by day 
and night. The temperature was 98° in the morning and 98.4° in the 
evening. She became steadily weaker, and was giddy when she stood 
up, and towards the end became sleepy all the time. Her urine was 
never very copious, and its specific gravity was always about 1080. She 
had a small ulcerated spot on her ankle, which could not be healed, and 
increased slowly in size. She died rather suddenly six weeks after ad- 
mission. 

On post-mortem examination, we found the scalp and skull-cap of a 
yellowish hue. The inner table of the skull-cap was irregularly thick- 
ened by bony masses ; the dura mater was leathery ; the pia mater was 
thickened, and could be removed from the convolutions with abnormal 
ease. The convolutions and brain generally were much atrophied, com- 
pensatory fluid taking its place. The convolutions stood out thin, small, 
loosely packed, and wedge-shaped. The fornix and corpus callosum were 
pale and soft. The lining membranes of the ventricles were roughened, 
with a trace of granulations. Sections of the brain showed an irregular 



DIABETIC INSANITY. 418 

mottling of a pink hue, and pallor of the gray substance of the convolu- 
tions. The whole of the cerebral substance exhibited a loss of consist- 
ence, and in the left corpus striatum there was a small localized softening, 
the size of a split pea. The encephalon only weighed thirty-eight ounces. 

Dr. Campbell Clark made some sections of the medulla for me, and 
they all show (1) great looseness of texture, (2) localized atrophies, (3) 
abnormally enlarged perivascular canals, (4) degenerated and partially 
atrophied cells, very many of which have undergone fuscous degenera- 
tion, their processes having largely disappeared, like the cells in senile 
dementia (Plate YIII. Fig. 4). On the whole, therefore, the pathology 
of diabetic insanity, so far as that case throws light on it, seems to be 
an innutrition and general atrophy of the brain, especially aifecting its 
convolutions. 

The following was another case: L. J., set. 57. Classical education ; 
no profession. Temperament melancholic. Disposition gloomy, variable, 
and excitable, implying the nervous diathesis. Habits steady, industrious, 
especially fond of figures. Eirst attack. Paternal uncle insane. Causa- 
tion, work and worry. One particular piece of business was the exciting 
cause of his first mental depression, and of the fancies that he was ruined. 
He became restless and sleepless, and could talk of nothing but this. He 
got worse, and tried to starve himself, fancying that he could not pay for 
his food, and had therefore no right to eat it. Talked of, but did not 
attempt, suicide. When I saw him, eighteen months after the beginning 
of his illness, he was much depressed, somewhat stupid, very obstinate 
and resistive, and looked as if absorbed in his own morbid ideas. Gets 
a little irritable and subacutely excited when pressed to speak or to take 
food. Attention much impaired ; memory seems good as to distant 
events. He has the delusions that he is ruined, that he has no money, 
that he should eat nothing because it cannot be paid for. His countenance 
is haggard, depressed, and vacant ; skin cold and clammy ; muscularity 
flabby ; fatness is deficient ; pupils equal and contractile ; motor, sensory, 
and reflex functions normal; lungs and heart normal, but circulation 
weak; tongue furred; bowels costive; no appetite; pulse 108, weak; 
temperature 99.8°. Unfortunately the urine was not examined at first. 

He ate only on great pressure, and he got no fatter. His skin became 
dry and harsh feeling. Mentally he remained doggedly and unreasonably 
obstinate as to dressing, undressing, going out, and especially as to taking 
his food. He read a little, and would sit by the hour making long calcu- 
lations, showing how, at the rate he was eating, all the food in the 
country would soon come to an end. Sometimes he would say he was 
being starved. He had no hallucinations. He had one or two small 
abscesses, which became ulcers, on his toes that would not heal. He was 
occasionally dirty. 

He was treated with quinine, iron, the phosphates, phosphorus pills, 
cod-liver oil and the hypophosphites, maltine, milk, cream, strychnine, 
vegetable bitters, and the mineral acids in succession or combination. 
He was sent for change of air to the asylum sea-side house in the summer. 
Sometimes temporary improvement took place, but he fell oft' and got 
thinner on the whole. He certainly could not have passed as much water 
as an ordinary diabetic or it would have been observed, but it wa^ not till 



414 

near the end of his life, two and a half years after the beginning of his 
illness, that his urine was examined, at Dr. Begbie's request, and found 
to be loaded with sugar. He frequently saw him with me in consulta- 
tion, but diabetes had never been suspected till towards the end of his 
life. He died suddenly of exhaustion, two years and eight months from 
the time of his attack. No post-mortem examination in this case was 
allowed. 

These two cases of diabetes have many mental symptoms in common, 
though they had some differences. They were both melancholic. They 
both imagined they had no money, and were ruined, and could not pay 
their debts. They both had a disinclination to take food. They were 
both wanting in affection for their children. They both were thin and 
weak. They both had a tendency to sores on extremities, with small 
healing power. But the one was more resistive and dogged ; the other 
more passive, inattentive, and utterly uninterested in anything in the 
world. Death in both cases occurred rather suddenly. 

3. Insanity of Bright' s Disease. — This is a variety of mental 
derangement, half delirium and half mania, which results from uraemic 
poisoning. I have met with several cases of this disease. Dr. Wilkes^ 
has published several cases of this kind, and Dr. Grainger Stewart says 
he has also seen similar cases. It usually occurs in chronic cases of 
Bright's disease, with contracted kidneys, where there have been enlarge- 
ment of the heart and a tendency to dropsy for some time, and where the 
central nervous system has been long subjected to the influence of imper- 
fectly purified blood. The symptoms present are mania of a delirious 
kind, with extreme restlessness, delusions as to persons round the patient, 
an absolute want of fear of jumping through windows, or other actions 
that would kill or injure. The symptoms are characterized by remissions, 
during which the patient is quiet, rather composed in mind, and rational, 
but very prostrate in body. One of my cases was L. L., a man of fifty, 
with a family history of insanity, who had once been much depressed in 
mind (but was not sent to an asylum) after a fever. He seems to have 
had heart disease for many years, and to have had Bright's disease for at 
least two or three years previous to his admission into the asylum. He 
had dropsy of his legs for some weeks before the mental symptoms began. 
He was at first morose and irritable to a morbid degree, and steadily got 
w^orse in mind, his symptoms changing to exaltation and excitement, 
fancying he could do wonders, had absurd schemes for making money, 
and threatened to murder everyone near him. On admission he was in a 
state of mental exaltation and excitement, gesticulating, saying he had 
been married and had no children (which were delusions), and his memory 
quite gone. His speech was thick and indistinct, his tongue coated, his 
pupils dilated, and slowly sensitive to light, the reflex action of the cord 
dulled, and the temperature below normal ; legs oedematous ; his lungs 
were dull at bases; his heart hypertrophied, with a loud murmur with 
first and second sounds; urine contained much albumen, and a few tube- 
casts, sp. gr. 1020. This man alternated between this state of mind and 
that of a drowsy, stupid, but fairly rational condition, till two days 

^ Journal of Mental Science, July, 1874. 



INSANITY OF OXALURIA AND PHOSPH ATU RI A . 415 

before his death, when he got semi-comatose, with periods of delirium. 
He only lived five weeks after admission, or about two months from the 
appearance of his mental symptoms. This is a typical case of the disease. 
No doubt the mental portions of his brain were the weak points of his 
central nervous system from his hereditary predisposition to insanity, and 
the uraemic poison took effect there instead of causing convulsions. 

4. Insanity of Oxaluria and Phosphaturia.— t-AII writers on the 
urine have noticed the hypochondriasis, depression of mind, want of 
energy and originating power, and the irritability that so often go along 
with the presence of much oxalate of lime or phosphates in the urine. 
Dr. Prout' thought that the mental state was probably the cause of these 
abnormal products in the urine, and he especially mentions, "a nervous 
state of the system, and particularly mental anxiety and fear," as causes 
that, "will frequently produce in many people an excess of the salt in the 
urine." Golding Bird^ says that "persons affected with 'oxaluria' are 
generally remarkably depressed in spirits, hypochondriacal, extremely 
nervous, painfully susceptible to external impressions, and in many cases 
labor under the impression that they are about to fall victims to con- 
sumption." He says, in reference to phosphaturia, that there are cases 
with this condition characterized by high nervous irritability, following 
injury to the spine. The late Dr. Begbie directed special attention to 
oxaluria as a cause of a nervous disorder, which was characterized by a 
very highly neurotic condition of the patient. He says such patients are 
commonly in the prime of life, belong usually to the upper classes, and 
have indulged freely in the good things, especially the sweets of the 
table. He says their sufferings often threaten their mental condition. 
" They are usually peevish, sensitive, and irritable, or dull and despond- 
ing, and melancholic." His theory of the causation of these miseries is, 
that they " flow from the oxalic diathesis from a poison generated during 
the process of digestion and assimilation, carried into the blood by the 
ordinary channels, but limited in its pernicious consequences by the busy 
agency of the urinary organs in separating it from the circulation, and 
discharging it from the system." Several of the cases he gives were 
almost insane, but I fancy few such require asylum treatment. He 
shows that the nervous symptoms are apparently a result of the oxaluria, 
and disappear under the treatment that cures it. There is, on the other 
hand, no doubt of the fact that oxalates may be found in very great 
abundance in the urine of persons in good health. Lehmann, Bence 
Jones, and Garrod, and many others, direct special attention to this fact. 
The former, along with many other physicians, think that its appearance 
is not at all essentially connected with any special disease or train of 
symptoms. Speaking generally, the chemical physicians who have 
written on the urine take this view, while the clinical physicians take the 
opposite. 

In a very considerable number of a certain class of melancholies, the 
irritable hypochondriacs, we find oxalates or basic phosphates in tlie urine, 
and the special treatment suitable for those conditions as an adjunct to 
the moral and tonic treatment of the melancholia seems certainly to be 

1 Prout p. 176, 2d ed. 2 q^ "Bird, pp. 250 and 807. 



416 POST-FEBKILE INSANITY. 

useful. I think there is scarcely enough evidence to show whether this 

condition of the urine is a cause or an effect of the brain state. 

5. The Insanity of Cyanosis from Bronchitis, Cardiac Disease, 
AND Asthma. — This is a form of delirium, with confusion, hallucina- 
tions of sight, sleeplessness, sometimes suicidal impulses, and vague fears. 
Those symptoms are usually worst at night, and often end in mental 
torpor, passing into coma. It is more commonly seen in persons of 
advanced age than in young people. In some degree the mental power 
is usually affected in most old persons who have diseases that prevent the 
blood being properly oxygenated. No doubt a hereditarily weak or a senile 
brain suffers more than a stronger brain in this way. 

6. Metastatic Insanity. — The typical rheumatic insanity is essen- 
tially a metastatic insanity, the diseased process leaving the joints, its 
normal seat, and attacking the nervous centres. I have seen more than 
one case where the healing of an old ulcer was followed by an attack of 
insanity. I have seen instances of erysipelas of the face "striking 
inwards" and causing an attack of acute mania. I have often seen the 
disappearance of a syphilitic psoriasis followed by melancholia, and its 
reappearance on the skin precede mental recovery. 

7. Post-febrile Insanity. — The next form of insanity I shall refer 
to is that called by Dr. Skae post-febrile insanity. The exhaustion of 
the vital powers that is caused by zymotic diseases sometimes takes special 
effect on the higher functions of the brain, and we have an attack of in- 
sanity resulting. The nervous affections that often follow fevers in 
children are well known. These, no doubt, are precisely analogous to 
the post-febrile insanity of the adult. The insanity which sometimes 
followed fevers, was known from the earliest times, and was evidently 
much more common two hundred years ago than now, but it was then 
ascribed not to the exhausting effects of the fever, but to its not having 
been treated with "sufficient dilution" and purges to carry off the entire 
materies morbi, thus leaving a dangerous element in the system, that was 
liable to fly to the head and cause insanity. Arnold thought that insanity 
was much less common in his time than in Sydenham's after fevers and 
agues, because they purged more than the old physicians, and used the 
Peruvian bark more freely. Post-febrile insanity is not specially confined 
to one kind of fever. 

I went over the records of over a thousand cases of insanity that were 
sent to the Carlisle Asylum, and I found that among those there had been 
ten cases of such post-febrile insanity, four of which followed scarlet fever, 
two smallpox, one typhus, one typhoid, one intermittent, and in the tenth 
case I could not ascertain the exact form. Those are small numbers on 
which to base any conclusions in regard to a disease, but I am not aAvare 
of any fuller statistics on the subject. I think those numbers represent 
in a general way the comparative frequency of its occurrence after the 
different fevers. 

Scarlatina is unquestionably the most frequent cause, and smallpox 
the next. It is said to follow typhus more frequently than typhoid, and 
as intermittent fever is now very infrequent in this country, this is a very 
rare cause of the disease. 

Whether this represents the comparative exhausting powers of the 



POST-FEBRILE INSANITY. 417 

poisons of those fevers on the brain, or whether scarlatina stands at the 
head of the list, from its greater frequency, or from its more common oc- 
currence in youth Avhen the brain has not attained its maturity, I am 
unable to say with certainty. The form of insanity that results after 
scarlatina is almost always characterized by symptoms of dementia which 
are incurable. 

We might expect this from the well-known occurrence of idiocy and 
epilepsy in children after this disease of sequelae and complications. 
More frequently than after any other fever we hear the remark — " Such 
a person has never been the same since he had scarlet fever." On the 
whole, I think there is fair ground for the assumption that the poison of 
this disease is more apt to leave permanent brain disease than any of the 
others. When mental symptoms follow the disappearance of scarlatina, 
they do so at once ; the patient not having an attack of acute excitement 
so commonly as that he is left after the disease in a state of partial dementia. 
The weakness of mind is not complete, but more of a partial imbecility, 
a blunting of all the mental faculties and affections, with attacks of sub- 
acute excitement and irritability. In two of my four cases there was 
deafness along with the imbecility, showing that the effects of the disease 
had not been confined to the brain convolutions, but had also affected the 
organs and centres of special sensation. 

The form of insanity that follows smallpox is of the same character as 
that of scarlatina, but is even more incurable. That of typhus and 
typhoid is more clearly the result of brain exhaustion from those diseases 
in cases where they have continued for a long time. The patient seems 
to come out of the fever, showing no particular mental symptom or in- 
sanity until some weeks afterwards, when he is attacked with acute ex- 
citement, or ''gets into a low way," and a long-continued, intractable 
depression results. Tuke and Bucknill and Maudsley say that the in- 
sanity that follows typhus is of a more incurable kind than that resulting 
from typhoid. Sydenham describes the form of insanity that used to 
follow ague, and in his time this seems not to have been uncommon. He 
calls it a peculiar form of mania, and says that the long continuance of 
the fever, and of its being of a quartan type, seemed to produce the mental 
symptoms more than any other circumstances. If treated by the exhibi- 
tion of strong evacuants it degenerates into hopeless fatuity. My single 
case of the disease was that of a sailor, who had regular attacks of ague, 
drank hard, lived on salt provisions during his voyage, and on his arrival 
had an acute maniacal attack. He was thin, pale, and slightly scorbutic. 
I treated him with abundant diet, malt liquors, fresh air, quinine and 
iron, and a few draughts of chloral at bedtime, and he was quite well 
again in two months, having gained twenty pounds in weight in that 
time. In this case, of course, there were the other causes of brain ex- 
haustion as well as the ague. 

Of my ten cases only the above-mentioned patient, and one of the 
scarlet fever patients, had acute symptoms of any sort, and they wore 
the only ones who recovered. All the others were incurable, six of them 
being hopelessly demented, and the two others hopelessly melanoliolio. 
There was hereditary predisposition to insanity in only three of the ten 
cases. 

27 



418 IXSANITY FEOM DEPEIVATION OF THE SENSES. 

Post-febrile insanity may be said, therefore, to be generally charac- 
terized by subacute symptoms, to result from the brain being poisoned 
by zymotic poison and exhausted by fever, not to require a hereditary 
tendency for its development, and to be a very incurable form of insanity 
from the beginning. 

I once met with a peculiar form of transient mania following an attack 
of erysipelas of the face in a lady, L. M., who, a fortnight before, had 
been attacked with erysipelas of the head and face of a very severe 
character, causing much swelling, shutting up of the eyes, and being ac- 
companied by slight delirium. All the acute symptoms of this had passed 
off, the temperature was down from 104° to normal, and the swelling of 
the face was abating, but still she could not open her eyes. About three 
days before I saw her she seemed to know that she w^as going out of her 
mind, for she asked her friends to keep her as long at home as possible 
before sending her away. She then began to wander in mind, and to have 
hallucinations of sight and hearing, to mistake identities, and to fancy 
she had a child. She would go on talking to imaginary people, would 
especially keep up long conversations with God, would ask Him quite 
familiarly what she was to do if any one requested her to take medicine, 
etc., and would fancy she got an immediate reply. Her amatory pro- 
pensities were exalted, and her religious feelings and emotions were both 
excited and perverted. Usually she lay in bed, but was at times very 
violent indeed. Her pulse was 86, and of fair strength, and her tem- 
perature 98.6°. She slept little. She took liquid food. She could 
open her eyes slightly and with difficulty, but seldom did so, and evi- 
dently preferred to keep them shut, and live in her own world of fancies. 
Her state much resembled a waking dream. Impressions on her senses 
of hearing and touch were acutely felt, however, and made much im- 
pression often in diverting her from her unreal beliefs and hallucinations. 

She got stimulants with a little chloral (ten grains) at night, and next 
day, thinking the best way to correct her false sense impressions was to 
subject her to true ones, she was got out of bed, made to open her eyes, 
and reasoned with as to the absurdity of her fancies, and certainly she 
seemed to be reasoned out of her delusions and hallucinations for the 
time, though she was unsettled in conversation. Her room was kept 
cool and well aired, and she was made to take much stimulants and 
nourishment. She showed a tendency to fall back once or twice into her 
former state, especially at night, but to a much less extent, and got quite 
well in a few days. 

I lately had a case of acute delirious mania of a very severe type fol- 
lowing an attack of measles in a young, strong, healthy lady. It ran a 
typical course, and she made a perfect recovery in a few months. 

8. Insanity from Deprivation of the Senses. — I saw a gentle- 
man, some years ago, who became melancholic and suicidal coincidently 
with his loss of sight from cataract, and who improved greatly after the 
operation for removing it was partially successful, so that he could again 
see even in a dim way the outer world. It is very common indeed for 
those who are deaf to become quiet, depressed, and irritable. It is also 
common for such persons to become subject to hallucinations of hearing, 
and so insane as to need to be sent to asvlums. I have now at the Royal 



INSANITY OF EXOPHTHALMIC GOITRE. 419 

Asylum four or five such cases. It seems as if they were so cut off from 
the outer world by their deafness that their subjective experiences became 
objective realities to them. In the case of all men the senses correct 
many "delusions." 

9. The Insanity of Myxcedema. — I have now had three cases of 
myxoedema sent to my care as patients at the asylum who were positively 
insane, and all the examples of the disease I have ever seen were more 
or less affected mentally, if they were not technically insane. The first 
case I had sent to the asylum was L. 0., a woman of thirty-eight, whose 
mother was said to be "nervous," and she was said to have been "drop- 
sical ' ' for thirteen years, which no doubt was the time she had labored 
under myxoedema. She had become lately violent, excited, confused, and 
full of changing delusions, with hallucinations of hearing. On admission, 
she was incoherent and sleepless. Under discipline and nursing, she 
became more quiet and slept better, but was still confused and stupid. 
She was sent home after about five weeks, her symptoms having become 
so much better that she did not require asylum treatment, the mania and 
delusions having disappeared, though confusion and mental enfeeblement 
remained. The next case I had was the asylum plumber, L. Q., aet. 54, 
who, having labored under myxoedema for four years, suddenly one day 
tried to poison himself in a deliberate reasoning way on account of a bad 
wife. In consequence of this and of his mental weakness he was made 
a patient in the asylum, but he soon got into such an improved condition 
that he was discharged from the books as a patient, and remains a sort of 
special indoor pensioner of ours, an illustration of myxoedema for the 
Cliniques and Medical Societies of Edinburgh. He is still alive now, 
after twelve years from the beginning of his disease, contented, torpid, 
enfeebled, suspicious, with no initiative, no temper, and no affection left 
for anyone, slow in his mental movements as he is in his muscles — in 
fact, he is mildly demented. The third case is that of L. P., set. 37 on 
her admission to the asylum in 1878. Three years before admission she 
became depressed with hallucinations of smell — affirming that everything 
smelt of gunpowder. After three years of depression, she became exalted 
in mind, with much excitement. Her mental condition was like that of 
a typical general paralytic, hilarious and facile, contented, impulsive, 
with delusions of grandeur, thinking her husband had lately come into a 
fortune. She now, after five years, is enfeebled in mind, silly in speech 
and conduct, very contented, with a thick, slow articulation, expression- 
less puffy face, with no affection and no keen desires. 

It seems, therefore, judging from those cases, that myxoedema always 
tends towards a mild dementia if it lasts long enough, and that before 
that occurs some patients may have maniacal and melancholic attacks. 

10. Insanity Associated with Exophthalmic Goitre. — I lately 
had the following very interesting case, which will be more fully reported 
by Dr. Carlyle Johnstone, the assistant physician in charge of it : 

L. S., admitted into the Royal Edinburgh Asylum on the 26th of 
November, 1881, set 32. She was a workingman's wife, of active, 
steady habits, and cheerful disposition, and the mother of three children. 
For the last three years she had been gradually losing ilesh and strength, 
and had latterly been treated for goitre. A fcAV days before her admis- 



420 INSANITY OF EXOPHTHALMIC GOITRE. 

sion she suddenly began to express delusions, and soon became intensely 
excited- When brought to the asylum, she was in a condition of acute 
excitement, writhing, struggling, and violently resisting all attempts at 
interference ; talking incessantly, and incoherently using profane and 
obscene expressions, and displaying many vague and fleeting delusions. 
In some respects her excitement was hysterical in its character. She was 
very emaciated, and her physical condition generally was very weak. 
She presented the ordinary signs of exophthalmic goitre — prominent 
eyeballs, cardiac disorder, and enlargement of the thyroid gland. There 
was slight elevation of the temperature, with a rapid, irregular, and 
feeble pulse. 

The maniacal condition persisted, with frequent remissions and exacer- 
bations, for about a couple of months, and the general health remained 
wretchedly poor. She was ordered tonics and the bromide of iron con- 
tinuously. A gradual improvement was then observed in the mental 
symptoms, and the relapses became less frequent and less serious. Five 
months after her admission, she was able to employ herself usefully in 
the female infirmary, and as her convalescence appeared to become estab- 
lished, she settled down into a steady house-worker, and behaved, except 
for occasional hysterical outbursts, in a sober, rational, and tolerably 
cheerful manner. With the abatement of the excitement, the state of 
nutrition became greatly improved — the increase in body weight being 
very rapid. There was little alteration, however, in the signs of exoph- 
thalmic goitre, and during her residence the patient only menstruated 
once. In addition to these adverse symptoms, nervous phenomena of a 
very grave nature began to make their appearance between three and 
four months after admission. These began with fainting seizures, followed 
by a feeling of numbness in the left arm, which, in subsequent attacks, 
extended to the whole left side. Gradually the power of the left limbs 
was entirely lost, and the sense of touch disappeared from the whole of 
the left side, while the sense of pain was increased. The left eyeball 
became more prominent than the right, violent headache set in, and 
patient began to vomit persistently. She died on the 19th November, 
1882, about twelve months after admission. 

The autopsy was performed thirty-six hours after death. The calva- 
rium, dura mater, and pia mater were considerably injected. There was 
great hypersemia of the left hemisphere, but in consistence and other 
respects that portion of the brain was tolerably healthy. The right 
hemisphere was very extensively diseased. Over the whole of the supe- 
rior and lateral aspects the pia mater was more or less firmly adherent, 
dragging with it, on removal, in several places, the whole depth of the 
cortical matter. The white matter w^as pink and mottled, and the cor- 
tical matter was universally soft and red, and in many places quite dis- 
organized. 

The optic nerves and tracts presented no abnormality ; the cellulo- 
adipose tissue in the orbits was increased in quantity ; the thyroid gland 
was much enlarged ; there was a large thymus gland ; the heart was 
slightly hypertrophied ; the other organs w^ere tolerably healthy. 

This case suggests several questions. If the extensive disease of the 
gray matter of the convolutions existed all the time, how was she so sane 



PSEUDO-INSANITY OF SOMNAMBULISM. 421 

mentally for a portion of it? Was the origin of the case a vaso-motor 
one ? What was the relationship between the exophthalmus, the goitre, 
and the brain disease? 

11. The Delirium of Young Children. — Few mothers of large 
families but have had experience of the delirium of young children. 
Some children are much more subject to it than others. Some children, 
in fact, never have an increase of temperature over 99.5° without being 
delirious at night. In most cases it is a pure delirium without conscious- 
ness, attention, or memory, but in some instances there are frightful 
hallucinations ; in others an excited melancholia of short duration, with 
violent screaming, tearless weeping, and all the usual signs of mental 
depression. I have seen a child of six have a regular attack of melan- 
cholia of this character lasting for a few days. The bromides and cold 
to the head with hot baths are, no doubt, the best treatment, with non- 
stimulating nutrients like milk, and febrifuges and diaphoretics. I have 
known a child of eight left very melancholic after an attack of inflamma- 
tion of the lungs had passed off, and after the temperature had fallen to 
normal. 

12. The Insanity of Lead-poisoning.— This is a variety of mental 
disease which Drs. Rayner, Savage, A. Robertson, and Atkins, have quite 
lately^ directed attention to. Though diseases of the nervous system 
from lead-poisoning have been long known to medicine, I have only seen 
one or two cases, and those not well marked, and complicated with 
alcoholism. All the cases have motor symptoms, either convulsions, or 
paralysis, or muscular tremblings. The mental symptoms are most 
various, from coma down to slight lassitude; but hallucinations, morbid 
elevation, maniacal attacks, delusions of persecution, have been the chief 
symptoms noticed in different cases. 

13. POST-CONNUBIAL INSANITY. — I lately had a patient, L. R., who 
became melancholic, suicidal, and very stupid three days after his 
marriage. He is now getting well. This has not unfrequently been 
observed. The mental excitement of marriage, culminating in an excess 
of sexual excitation, is liable to upset the convolutional stability in certain 
persons predisposed to mental disease. In my experience it has been a 
curable and not a prolonged form of mental disease. Some brains are so 
liable to be upset in their mental working, that it is no wonder the 
in tensest known physical excitement produces this effect, just as other 
brains are upset in their motor centres in like circumstances and an 
epileptic fit occurs on each occasion of intercourse. 

14. The Pseudo-insanity of Somnambulism. — One cannot admit 
that the actual state of somnambulism is a form of mental disease in any 
true or scientific sense, for the patient is necessarily asleep. But heredi- 
tarily it is often very closely allied to mental disease and to epilepsy, and 
I have ascertained that some of my insane patients had been sleep- 
walkers during the period of adolescence. JNIost bad and confirmed 
sleep-walkers have a neurotic heredity, or a nervous temperament, or both, 
though it is fortunately quite certain that few of them ever become 
insane. Acts of violence, homicide, and suicide may be done in a state ot 

^ Journal of Mental Science, July, 1880. 



422 PSEUDO-INSANITY OF SOMNAMBULISM. 

somnambulisin. I lately saw in the Edinburgh prison a man named 
Simon Eraser, whose heredity was highly neurotic, who had been an 
aggravated sleep-walker all his life, who during his somnambulism had 
vivid conceptions, hallucinations, and illusions, and who in that condi- 
tion did all sorts of purposive acts in accordance with those false beliefs. 
He remembered his somnambulistic impressions in a vague way after he 
awoke. He was most difficult to awake. He once went up to his neck 
in the sea in Norway, and did not awake. At last, one night he got up, 
and while in a state of somnambulism, imagining he saw a white animal 
in the room, he seized it and dashed it against the wall. This turned out 
to be his child, whom he thus killed on the spot.^ He was passionately 
fond of the child, and had played Avith it the last thing before it had gone 
to sleep. The question is — What should be done with such a man 
to protect himself and others, he being perfectly sane when awake? 
Neither the lunacy nor the criminal laws at present make any provision 
for the treatment of such a state and its consequences. 

1 Dr. Yellowlees has given a full account of this case and the trial in the Journal of 
Mental Science, vol xxiv. p. 451. 



LECTURE XIX. 

THE MEDICO-LEGAL AND MEDICO-SOCIAL DUTIES OF MEDICAL 
MEN IN EELATION TO MENTAL DISEASES. 

The medical profession has grave medico-legal responsibilities thrown 
on it by the provisions of many of the forty, enactments that stand on the 
Statute Book relating to the insane. In addition to those statutes, 
judges, juries, and administrators of the law constantly call in medical 
men to help them in the solution of questions that they only can solve. 
There are few things about which the British public is more sensitive than 
those relating to the liberty of the subject, to civil capacity, and to the 
control of property. In addition to these responsibilities, there are most 
delicate duties of a purely medical and medico-social kind thrown on our 
profession by the exigencies of practice, and the impossibility of finding 
elsewhere so qualified and wise an adviser as the family doctor. There is 
no doubt that all those duties should be done with much care, searching 
inquiry into facts, and a grave consideration of the whole efiects of any 
opinion expressed, or ©f any act done ; and a special knowledge of the 
subject, experience, sound judgment, and caution, are all qualities 
requisite in dealing medico-legally with the insane. 

The chief medico-legal and medico-social duties of medical men in 
relation to mental diseases may be thus classified : 

1. Taking the responsibility involved in treating cases at home, placing 
them under the care of attendants, advising that they be restricted as to 
liberty, and prevented from transacting business. This, in doubtful 
cases and in the early stages, of the disease, is often a very serious thing 
to do. The patient does not know he is ill, says in fact he is quite well, 
resents as an insult and a degradation being put under control, and 
threatens all who have to do with it with the most dire consequences. 
The doctor often loses the family practice after a case of insanity, 
whether the patient recovers or not. The only sound and safe rule for 
the doctor is to make it clear that he only advises and does not take any 
legal responsibility whatever for the steps by which a patient is controlled. 
Let that fall on a relation who has the le<]i;al rio-ht to take measures for 
the safety of the patient, and on no account be assumed by the doctor, to 
whom the law gives no such authority whatever but to grant certificates. 
If the patient is removed to lodgings to be under treatment, the relatives 
must do so. It need not be the nearest relative. It is often desirable to 
have family councils under tbose circumstances. Especially when 
husbands or wives are mentally aftected, some of the blood relations of 
the patient should, if possible, be taken into consultation. But as 
regards the doctor the rule is clear. Let him advise, but not act. I have 
even in some rare cases refused to take the responsibility of regular 



424 DUTIES OF MEDICAL MEX IN 

attendance and treatment, without first getting a letter of protection from 
legal risk. The attendants in charge are the servants of the relatives, 
and under their order technically and legally, however much in fact they 
may be under the doctor's directions. 

In England a patient can be treated at his own home or anywhere else, 
if not '' for profit," without certificates of lunacy, as long as his friends 
desire, and so long as he is not badly treated, which last procedure 
subjects those responsible for it to very heavy punishment. In Scotland, 
a patient can be treated, with a yiew to cure, anywhere out of an asylum 
for twelve months without formal certificates, if a medical opinion to that 
effect and intimation is sent to the Commissioners in Lunacy. I do not 
wish to discourage the early treatment with a view to cure of insane 
patients in priyate houses. I only point out the conditions on which only 
it can legally be done. 

2. The most common of all the medico-legal duties thrown on medical 
men is that of signing the statutory medical certificates for placing 
patients in asylums, or under care in private houses. This is done for 
the proper treatment of the patient, and often for his safety as well as for 
the safety of the public. The form of certificate is fixed by statute, and 
no other form will do. The form is practically the same in England, 
Scotland, and Ireland, though the mode of placing a patient in the 
asylum is different in the three countries. In England and Ireland 
a private patient can be placed in an asylum on the "order" of a relation 
or of anyone else after the two medical certificates have been obtained ; 
in Scotland the sheriff must sicrn the "order," after havinor seen the cer- 
tificates. Pauper patients are placed in asylums in England and Ireland 
on the order of a magistrate, who must see the patient, and on one 
medical certificate, while in Scotland pauper patients are placed in asylums 
in the same way as private patients, that is, on two certificates and 
a sheriff's order. 

As to the grounds on which a British subject can be legally deprived 
of his liberty on account of lunacy, the common law of England only 
recognized as a sufiicient cause danger to the patient or to the public, 
and a recent decision seems to imply that some judges still hold that to 
be the law. But by the universal practice of the country, sanctioned by 
the Commissioners in Lunacy, the recent statutory law is taken as super- 
seding or supplementing the common law; and that, without defining 
insanity, or prescribing any specific grounds on which a patient may be 
detained as a lunatic, clearly enacts that "care and treatment" are the 
chief objects of his detention, and his being dangerous is nowhere made 
a siJie qua non. This being so, the first thing a medical man with an 
insane patient who needs care and treatment in an asylum, or to be 
boarded with a private family, has to do, is to make up his own mind in 
regard to the definite grounds on which the steps are to be taken. Having 
done so, his next business is to convince the patient's responsible relatives 
of the necessity for certification. In doing this, it is far better not to 
press them too strongly at first if they do not see the necessity for it. All 
that is necessary is to explain that the responsibility rests on them, not 
on the doctor. It may in some rare cases be necessary, before certifying, 
to get a letter from a responsible person, protecting the doctor from risk 



RELATION TO MENTAL DISEASES. 425 

of a legal action. That is a risk no medical man in signing a certificate 
of lunacy should subject himself to if he can help it. The lunacy statutes 
give exemption from actions if the facts are correct, and the certificate 
hona fide and correctly filled in ; and if in spite of this, under the com- 
mon law, actions can then be brought against medical men for doing a 
statutory duty in a legal way, they must just protect themselves by a 
letter of indemnification, or as best they can. In the case of pauper 
patients, the chief responsibility undoubtedly rests on the medical man, 
to whom the relieving ofiicers or inspectors of poor must refer the ques- 
tion of asylum treatment, and must act on his opinion. 

In solving the question of w^hether a patient should be certified as a 
lunatic or not, the first thing, of course, to ask one's self is, " Is the patient 
insane?" And it is well to be prepared to say what kind of insanity he 
labors under. To determine this question, one must have evidence of 
mental disease observed by one's self, but may also use any facts proving 
it as ascertained from others who have seen the patient. If he is insane, 
then comes the further question, " Is he a proper person to be detained 
under care and treatment?" Many persons are insane in a medical and 
even in a legal sense, yet have so much self-control left, or their mental 
peculiarities are so slight and harmless, that they are not proper persons 
to be detained under care and treatment. I would say that the chief 
things that constitute the statutory fitness are danger to themselves or 
others ; disturbance of the public peace ; inability to care for and manage 
themselves and their affairs ; acute mental symptoms of any kind ; or 
amenability to curativer treatment which cannot be applied without certi- 
fication. No doubt '- all sorts of considerations — social, monetary, and 
domestic — come in before determining the expediency of certification. 
One has to ask what are the reasons for his removal from home, where 
he would naturally be in sickness, and how will it affect him and his 
affairs generally ? Then, of course, it is proper, having determined that 
he should be certified, to ask what legal risk there is to yourself or to his 
relations. I know an undoubtedly dangerous lunatic who has kept him- 
self out of an asylum by bribing one member of his family by money 
gifts to oppose his seclusion under all circumstances, and by threatening- 
anyone of his children who moves in the matter with disinheritance in 
his will. It may be necessary to see the patient several times before you 
can make up your mind. When those questions have been answered, 
and you proceed to certify, (a) fill in the first and purely formal part of 
the certificate in all cases as if it were an important business and legal 
document, looking at the directions on the margin. Our profession is 
not always sufficiently particular about this. Lawyers look on this part 
as of much importance. Not to designate the patient, and put in his 
residence at the proper place, is, according to Sir Cresswell Cresswell's 
judgment, to invalidate the whole document, and the English Commis- 
sioners always return it to the writer for correction if this is not done. 
The reason, no doubt, is that, there being ten thousand Tlionuis Jones in 
the country, it is necessary to discriminate clearly which one is tlie hmatic. 
In England and Ireland you must have seen the patient within a week 
of certification, in Scotland on the same day. 



426 DUTIES OF MEDICAL MEX IN 

(b) Then comes the most important part of all, viz., the '' facts indi- 
cating insanity observed by myself." Without these facts the certificate 
is not valid at all. By all means put in first the most evident and out- 
rageous insane delusions the patient labors under in as crisp and clear a 
way as you can. No evidence of insanity is so satisfactory to lawyers as 
insane delusions. Next to those in cogency come incoherence of speech, 
or shouting, or outrageous conduct, or loss of memory and reasoning 
power. Put into the certificate some of the patient's very words, if 
possible. Next to those come such "facts" as relate to the patient's 
appearance, expression of face, and manner. If you .have known him 
before, any changes from his normal condition should be noted. By the 
way, in putting down delusions it is necessary often to add to a statement 
of one, the words " which is a delusion." Some things may be quite 
true, e.g., "He says he has £10,000 a year," and therefore needs this 
explanation. On the other hand, such delusions as " Says he is God 
Almighty " do not need anything of the kind. If any suicidal or homi- 
cidal expression can be got hold of, put it among the facts, but usually 
these have to come under the "facts communicated by others." Negative 
signs, such as absolute taciturnity, insensibility to impressions from with- 
out, are good enough "facts." It is better to put no "facts" that do 
not clearly indicate insanity, if possible, but there are some cases where 
the evidence must consist of lesser things than those I have mentioned 
put in a cumulative way, e. g., " His manner is very peculiar. He is 
slightly incoherent and silly in speech. His memory is impaired some- 
what. He has no sane interest in his affairs or in his relations or 
belongings. His eye is vacant in expression. His whole conversation 
gives me the impression that he is unfit to manage his affairs," were 
really all the facts observed by myself that I could put down as the results 
of one interview with a person of mildly enfeebled mind. It is quite pro- 
per to use facts observed at previous interviews, though it is better to use 
those at the last interview if possible. 

I could give instances of most ridiculous "facts" put into lunacy 
certificates by medical men. "He is incoherent in his appearance." 
"Eyes restless and wandering, but following the usual occupation of 
breaking stones." " She says she is in the family way (she had a baby 
in a few months)." "Reads his Bible, and is anxious about the salva- 
tion of his soul," are examples. 

Never put in such statements as these — " He has no delusions." " His 
self-control is not lost." Those, in fact, prove sanity, and are not un- 
common. 

(c) The "facts indicating insanity communicated to me by others" 
that follow, are very important as subsidiary and not essential points of 
the certificate. Among them you can insert descriptions of previous 
aggravations of conduct and speech, of attempts or threats of suicide, or 
danger to others. You must put down the name of your informant. 

(d) The signature, residence, and dating must be carefully done. 
After the whole certificate is completed, I advise every man to run it 
over carefully. Few men are so accurate that they will not sometimes 
omit something. 



EELATION TO MENTAL DISEASES. 427 

The greatest tact is necessary often to bring out the real condition of 
a patient's mind. This is often impossible, in fact, even when you know 
on good evidence that he is insane. Especially is this the case when he 
thinks you are a doctor come to certify him. He then naturally conceals 
his delusions, and puts his best foot foremost. Sometimes a little stratagem 
is necessary. The weak are always cunning, and it seems as if this quality 
was exaggerated in some insane patients. By all means get the cue to his 
delusions if they exist, and as full a knowledge of the patient's case as you 
can before you see him. I have more than once entirely failed to educe 
facts enough on which to found a certificate in the case of a man I knew 
to be insane and dangerous. I do not consider it a justifiable thing to 
give the patient drink in order to make him speak what is in his mind, 
or to bring out his peculiarities, though I have known it done more than 
once. 

3. Medical men have to give certificates of sanity as well as of insanity 
sometimes. These need great care, much circumspection, and consider- 
able inquiry into the facts of a man's life and behavior. I have on two 
occasions had insane patients leave the asylum and return to me Avith 
certificates of sanity got from incautious doctors. In one case the patient 
produced and kept it as a good joke. It would be an awkward thing for 
the certifier if, after getting such a certificate, the patient went and made 
a will, or killed himself. In a way, a certificate of sanity needs more 
inquiry before it is given than a certificate of insanity. Certificates of 
sanity are needed to set aside a Curator Bonis, and often also before a 
man is allowed to resume employments and public appointments. 

4. When a man is ipso facto deprived of his civil rights and the 
control of his property by being put into a lunatic asylum, he must have 
his property looked after and administered for his benefit, and another 
legal process has to be gone through for that purpose. In England and 
Ireland affidavits have to be given, stating facts indicating insanity, and 
especially incapacity to manage property, which are sent to the Court of 
Chancery, and on them, as prima facie proof, an inquisition de hmatico 
inquirendo is held by a "Master in Lunacy," sent to the patient's resi- 
dence for the purpose, at which the medical man and others have to give 
viva voce sworn evidence. If the patient is found lunatic, one person is 
appointed "Committee of the person," to control the person, and another 
"Committee of the estate," to manage the property, and no further 
certificates are needed for placing him in an asylum. This is a cumbrous 
and expensive, though an efficient and fair process. If the property is 
under XIOOO in value, the process is simpler and cheaper. Some such 
process would always be necessary for doubtful and important cases, but 
in ninety-nine out of a hundred it is a simple, unnecessary waste of 
money and judicial talent. The Scotch process is far simpler and less 
expensive. Two doctors sign certificates "on soul and conscience" of 
the man's "insanity, incapacity to manage his own affairs, or to give di- 
rections for their management," and those are presented with a petition 
from a near relation, stating the amount of his property, to a judge of 
the Court of Session, who orders them to be intimated in a certain place 
in the Court for eight days, after which, if there is no opposition, a 



428 DUTIES OF MEDICAL MEN IN 

Curator Bonis is appointed, wlio then manages tlie lunatic's property, 
and acts for him, after finding due caution for the proper performance of 
his duties. He has to present an account of his intromissions to the 
Court every year. The weak point of the Scotch system is, that usually 
no proper guardian of the lunatic's person is appointed. The nearest 
relative commonly acts as such. Occasionally a Curator Dative is ap- 
pointed to control the person, but this, with the process of " Cognition," 
are cumbrous, antiquated processes seldom resorted to. 

5. Medical men are often called on to give evidence as to the existence 
or not of mental disease in persons accused of crime, to enable the law to 
fix or to absolve from responsibility. In Scotland the procurator-fiscal 
usually has a medical adviser, with a view to determine the kind of pro- 
ceedings to be taken in cases where crime, danger, or disturbance may 
have been the result of mental disease. 

Crime is usually committed in mania, epileptic insanity, and alcoholic 
insanity, and sometimes in puerperal insanity, delusional and homicidal 
melancholia, sometimes in dementia and congenital imbecility in an im- 
pulsive way, and also in impulsive insanity, where there are uncontroll- 
able homicidal, kleptomaniacal, pyromaniacal, destructive, or animal 
impulses. Some of the complications of mental disease with the effects 
of drunkenness are often most puzzling both to medical men and to 
lawyers. My experience is, that crime is usually committed at the same 
stage of attacks of insanity that suicides are ordinarily committed, viz., 
in the incipient stage. 

There has always been a tendency towards a divergence of view between 
medical men and lawyers in regard to the amount and kind of mental 
disease that should exempt from punishment for crime. Certainly the 
law has gradually come round more and more towards the medical view — 
has, in fact, recognized the facts of nature in mental disease. Judge 
Tracey held that, except a criminal was irresponsible as a wild beast, 
he should suffer punishment. Lord Mansfield held that a "knowledge 
of right and wrong" was the test. The twelve judges declared in 
M'Nauo-hton's case that a knowdedcce of rio;ht and wrono- in relation to 
the act committed should be the true legal test ; Lord Denman said that 
legal responsibility should depend on the presence or absence of insane 
delusion ; Lord Moncrieif has laid it down that a man's habit and repute 
as to sanity among his fellow-men who knew him well should determine 
his legal responsibility for any crime committed. At last the new 
criminal code of Mr. Justice Stephen proposes to make the man's power 
of controlling his actions the test, and with that view every medical man 
will agree. He says — " The proposition which I have to maintain and 
explain is, that if it is not, it ought to be the law of England, that no act 
is a crime if the person who does it is, at the time when it is done, pre- 
vented either by defective mental power or by any disease afi'ecting his 
mind, from controlling his own conduct, unless the absence of the power 
to control has been produced by his own default." While judges during 
three centuries were laying down these rules of law, men that we now 
hold to be insane were taking away their own lives by the hundred every 
year, most of them knowing it to be wrong and yet doing it — a "crime," 



RELATION" TO MENTAL DISEASES. 429 

and a ''motiveless" one in most cases. Those suicides were surely thus 
exhibiting to all who had eyes to see, that, in this respect at all events, 
something was interfering between every natural instinct, every eiFort of 
will, and every motive of ordinary human action — that something being 
disease and disordered function of the brain. 

No doubt there are many difficult cases — cases on the borderland of 
disease, cases where vice and mental disease are mixed up puzzlingly, 
cases of mild enfeeblement of mind, cases of drink voluntarily taken 
when its effects were well known, and after being taken crime was com- 
mitted in a condition of delirium or short frenzy. We must admit we 
have no definite test as yet for detecting minute amounts of mental dis- 
turbance. I only wish we medical men were placed in a more satisfac- 
tory position before giving evidence. The whole facts on both sides are 
seldom put before us, and we are regarded and treated in the witness-box 
as partisans — a position that we should resent as derogatory to science. 
Certainly we should never become partisans willingly. 

6. We are often appealed to as to the capacity of a man to make a 
will, or to transact ordinary business, or to contract marriage. The 
principles on which our opinion should be founded for the two latter 
purposes are just those on which we act in determining the question of 
sending a patient to an asylum. In regard to will-making, great atten- 
tion has been directed to the subject, and there are certain fixed legal and 
medical principles that should be kept in mind by us. The great trouble 
is that we are usually not consulted at the time of making the will, when 
the real capacity of the testator could be examined into, but are placed 
in the witness-box after he is dead with one-sided, imperfect information, 
and with every motive operating on the side that consults us to prevent 
us getting at all the facts. In will-making we must enlarge our ideas of 
the disturbances of the mental functions of the brain beyond those com- 
prised under technical insanity. The senile dotard, the man exhausted 
in strength from disease and approaching death, the man confused in 
mind from fever and drink, the man distracted by terrible pain, the man 
whose condition is weakened so that he is made mentally unresisting and 
facile by disease and by the near approach of death, may all require their 
testamentary capacity to be tested. It is most important that a skilled 
and experienced medical man should be asked to examine into the testa- 
mentary capacity of such cases before the destination of great sums of 
money is irrevocably decided by a document that above all things needs 
soundness of judgment for its validity. It would be well were our pro- 
fession more called on for this purpose. I was once told by a distin- 
guished counsel, with a large experience in the Probate Court, that he 
had never known a will upset where a respectable doctor had witnessed 
it after examining into the testator's state of mind, and a respectable 
agent had drawn it up, neither of them taking any benefit under its pro- 
visions. 

It may be held as proved by legal decisions that a lesser amount of 
mental capacity is needed for making a valid will than for managing 
property or enjoying personal liberty. Patients in asylums have made 
good wills. Patients with insane delusions that did not affect the provi- 



430 DUTIES OF MEDICAL MEN IN 

sions of the will have been held by the highest tribunals to have made 
good wills (Banks vs. Goodfellow). Very facile persons have made good 
wills, and those on the point of death constantly make wills that stand, 
while wills with the most absurd provisions have stood in law. 

When a medical man is asked to examine into the testamentary capa- 
city of a patient, he should insist on seeing the patient alone, or at all 
events only in the presence of a nurse or a family agent, and the first 
thing to be ascertained is this, (a) "Is the patient free from the influence 
of drink or drugs, and in his usual state?" Then (b) "Does he know 
the nature of the act he is to perform, and the effect of the document he 
is to sign?" The next thing (^c) is to find out if he is not influenced in 
the doing of it, or in regard to any of its provisions, by insane delusion, 
or by an insane, morbidly enfeebled state of mind. Then (d) ascertain if 
there is facility of mind from bodily weakness or any other cause, or 
undue influence being exercised from without. Here is where you will 
find the benefit of being alone with the patient. I remember an old 
dying man confessing to me, when alone with him in these circumstances, 
that his niece, who was also his nurse and constant companion, was really 
compelling him against his judgment to make a will in her favor, his own 
volitional and resistive power being weakened by his state of bodily weak- 
ness and dependence. The influence exerted on many patients in bodily 
weakness, especially if it has been prolonged, by a nurse constantly in 
attendance, is sometimes absolutely dominant, and quite irresistible by 
the w^ill of the patient. A very interesting bit of medico-psychology 
this is. 

Supposing you are satisfied so far; the next thing (e) is to make the 
intending testator go over the particulars of the disposition he wishes to 
be made, without prompting, or suggestion, or leading questions. And 
he should be made to do this twice, with certainly a quarter of an hour's 
interval between the two statements. You can then see if the disposition 
is a natural one, and find out from him the motives for the will being 
made, and for any provision of it that may seem strange. In fact, are 
the whole motives of action of the man quoad the will, sane, reasonable, 
and uninfluenced by morbid motives? Is it the act of the man himself 
exercising his own will spontaneously? I remember being called to see 
a man who was dying of bronchitis and heart disease, with his breathing 
impeded, his strength ebbing aAvay, and his mental power impaired by 
the non-oxygenated blood supplied to his brain. He had made a will in 
favor of a former mistress, and was in a state of great remorse, and 
wanted to leave his money, which was considerable, to his relatives. But 
he could not twice over remember all the provisions — these being a little 
complicated. I refused on this account on two occasions to say he had 
testamentary capacity. But, as sometimes happens, he became more 
clear in mind before death, and I was hurriedly sent for late at night to 
see him. He clearly went twice over the provisions he wished made in 
his will, and told me why he wished these made. His reasons were 
natural and right. The lawyer was there with the document drawn up, 
and the testator had just power to make his mark before he died. Yet 
this will was held good in law in spite of an attempt to upset it. The 



RELATION TO MENTAL DISEASES. 431 

last tiling (/) you have to ascertain is if the intending testator knows in 
a general way the amount of the property he has to bequeath. I lately, 
on getting to that point in the case of a very sensible-looking man, was 
astonished at being told by him that he was worth c£100,000, which I 
knew to be quite impossible, and of course no will was made. 

It is most necessary not to let a good motive make us sanction a bad 
will, however natural its provisions may be, however much trouble or 
expense it may save. I am frequently asked to sanction wills being 
made by persons unfit to make them, on account of the convenience of 
having a will or the saving of expense and trouble. I have found but 
little realization of the impropriety or illegality of getting dying people, 
or those whose minds were enfeebled from paralysis, who did not really 
know what they were doing, to sign wills as a matter of convenience, 
even among conscientious reputable people. 

7. The detection of feigned insanity is a duty sometimes laid on a 
medical man. There are no fixed rules or tests by which feigned in- 
sanity can be detected. I need hardly say we have first to see if the 
type presented is that of an ordinary kind of insanity. Most imitators 
mix up incoherent maniacal symptoms with silliness, and Avill talk no 
sense at all, and pretend to know nothing. In fact, they overdo their 
part. The patient should be carefully watched all the time, sometimes 
ostentatiously watched to keep him *at it for a long time, and then again 
when he does not know he is observed. No sane man can imitate the 
dry skin and lips, furred tongue, constant restlessness by day and night, 
high temperature, and constant sleeplessness of acute delirious mania, 
which for a short time they often try to simulate. A man imitating the 
shouting, etc., of acute mania perspires freely, while an acutely maniacal 
patient seldom does so. The sensibility to pain should be tested, and 
sometimes, in prisons, a battery is found useful in the case of old crafty 
malingerers. I have heard of a man being put under the influence of a 
drug before the doctor was known to be coming, in order to produce a 
real stupidity with confusion of mind. I have been deceived by a clever 
imitator of acute mania so far as my conclusions were arrived at from 
one visit. 

I have known a really insane man assume an exaggerated insanity to 
make his friends think the asylum was doing him harm ; and a sort of 
grotesque semi-volitional imitation of mania is common in hypochondri- 
acal melancholies to convince their friends how ill they are; while in 
hysterical girls imitations of maniacal attacks and of unconsciousness are 
very common to excite sympathy and attract attention. 

8. One of the most difficult and often most responsible duties that fall 
to a medical man's lot is to give confidential family advice about engage- 
ments to marry when one party has been insane, is threatened with 
insanity, or has an insane heredity, to advise as to the education and 
profession of children of a very neurotic heredity, and to advise as to 
the significance of sudden changes of conduct and sudden outbreaks of 
gross immorality, or of a tendency to unnatural crime, or other motive- 
less and unaccountable conduct in previously reputable sane people. 
Such advice may have the most serious consequences, blasting lives that 



432 DUTIES OF MEDICAL MEN IN" 

might have been happy. My feeling is always against the marriage of 
women who have been insane. I always advise young men or young 
women to avoid marrying into a very neurotic and insane stock, if their 
affections have not gone too far. The risk is very great. I agree with 
the French medical opinion that there is a special tendency for members 
of neurotic families to intermarry, and an affective affinity among such 
that tends towards love and marriage. That is no doubt bad for the race, 
and as physiologists w^e should try and stop it when we can. To have a 
neurotic young man marry a fat, phlegmatic young woman may be quite 
admissible, and a good safe stock may result. But w^hat are we to say 
about the marriage of the neurotic, thin, hysterical young w^omen, with 
insanity in their ancestry ? We know they wdll not make good or safe 
mothers. Therefore, in them we ought to discourage marriage. How- 
ever good its physiological effect might be on the individual, bad mental 
and bodily qualities, as well as tendencies to disease, are propagated to 
future generations. They leave the world worse than they found it 
thereby, the disease and therefore the misery in it being increased. The 
possible compensation of a genius once in a while is not to be trusted to. 
I believe a healthier kind of genius would result from better stock. 
Science, till it discovers a way of correcting such bad stock, must say, 
do not propagate it. A sporadic case of insanity, or of senile break- 
down imitating insanity, may occur in almost any family. That would 
not warrant any such advice about the marriage of relations as I have 
been giving. The relatives of such a case may all be perfectly sound. 
I am speaking of families in which the neurotic temperament, and espe- 
cially those in Avhich the nervous diathesis, is present. If such persons 
are to marry, do not let them marry young, and let them marry into 
a sound, muscular, fat, non-nervous stock. Though the contrary has 
been the rule, my advice has over and again been taken, and engage- 
ments to marry not entered into on the ground of bad heredity. If you 
are asked about any young man or w^oman, "Is he or she likely to 
become insane or not?" say that science does not yet enable us to 
answer that question. 

As to the mode of education of the children of insane or neurotic 
parents, there can be no doubt whatever that it ought to be on physio- 
logical lines, and under medical advice. Such children should all be 
brought up in the country, and fed mostly on milk and cereals, and 
should have lots of fresh air, and no improper excitement, with few 
children's parties. They should have well-ventilated class-rooms, short 
school hours, and their lives and time should be systematized. Their 
weak points should be corrected by their modes and conditions of life. 
They should be kept fat, if possible, one and all. They should have no 
alcohol, and no tobacco till after twenty-four. At the coming on of the 
reproductive period of life, special care should be taken with them. The 
sexual appetite is most difficult to manage in them, and by them. It is 
often strong, disturbed, and apt to take unnatural forms, while the power 
of control over it is apt to be small. The occupations they choose should 
not imply intense head work, or a sedentary life, or excitement. Make 
them colonists, sending them back to nature, or get them into fixed 



EELATION TO MENTAL DISEASES. 433 

salaried places with systematic work, and a regular holiday. The worst 
of it is that such persons often tend to do exactly the reverse of all 
this. Some especially neurotic children need very special modes of 
education. I have seen cases who could not safely be sent to school. 
Through precocious stealing, lying, and vice, they were constantly get- 
ting into trouble. They were without much moral sense or self-control, 
and had erratic, motiveless ways. I have seen good' results with such 
children sometimes by placing them in a quiet family, under motherly 
care, in the country, under special rules and guidance, and away from 
much temptation. Such children are the stock out of which the insane, 
the masturbators, the dipsomaniacs, and the motiveless criminals arise, 
with a poet or a genius to redeem the class once in a century, and to 
vindicate nature's law of compensation in the world. 



28 



ABSTRACT 



STATUTES OF THE UNITED STATES, AND OF THE SEVERAL 

STATES AND TERRITORIES, RELATING TO 

THE CUSTODY OF THE INSANE. 



BY 

CHARLES F. FOLSOM, M.D., 

FELLOW OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES ,* ASSISTANT PROFESSOR OF MENTAL 

DISEASES, HARVARD MEDICAL SCHOOL J PHYSICIAN TO OUT-PATIENTS WITH 

DISEASES OF THE NERVOUS SYSTEM, BOSTON CITY HOSPITAL. 



WITH THE ASSISTANCE OP 



Mr. HOLLIS R. BAILEY 

ATTORNEY AND COUNSELLOR-AT-LAW. 



GENERAL CONSIDERATIONS. 



The insane asylums in the several States are, as a rule, under the 
direction of a board called trustees, directors, commissioners, visitors, 
managers, regents or administrators. These boards are in some cases 
elected by the legislature, more commonly appointed by the governor of the 
State, with or without the advice or consent of the council, or senate, or 
legislature. The boards are required to visit the hospitals at stated 
intervals, and to make annual or biennial reports to the governor or to 
the legislature. For the most part they appoint the medical officers of 
the asylums, generally with the approval of the governor. In some 
States the governor appoints such officers. In Maine one member of the 
board must be a woman, and in Iowa two may be women. 

In West Virginia the board is app'ointed by the board of public works. 
In Florida, Nevada, Rhode Island, and Wisconsin, the board of commis- 
sioners of charitable and correctional institutions is the board of trustees. 
In the District of Columbia the visitors are appointed by the President. 
In North Carolina, Tennessee, and Virginia, there are separate asylums 
for negroes. County asylums, where they exist, are not much better 
than almshouses or houses of correction for the most part : and the laws 
requiring them, in the few States where there are such, are often disre- 
garded. In Massachusetts there were never more than three, and there is 
now only one. 

The various asylums have different by-laws regarding payment of dues 
for patients, etc. Women are employed as physicians in some, and in 
one State, Nebraska, there must be one female physician. 

In those States where the laws do not specify regulations for the com- 
mitment, or admission, of private patients, the trustees are allowed to in- 
clude that matter under their by-laws ; and they generally prescribe a 
medical certificate from one physician, or two, which in some States must 
be signed under oath. 

The civil laws of all the States provide the right of habeas corpus, 
according to law, and the possibility of a jury trial to a person demand- 
ing his discharge from an insane asylum ; they deal in various ways with 
the disqualifications of the insane as to holding office, voting, serving as 
jurors or witnesses, managing property, marrying, and guardianship. In 
a few States incurable insanity is ground for divorce. 



APPENDIX. 



ALABAMA.' 



Patients are received at the insane asylum from the several counties 
of the State in proportion to the numbers of their insane population. In 
order of admission the indigent insane have precedence over those able 
to pay, and recent cases over those of long standing. 

Paying patients are received on the following requirements : (1) security 
for the payment of charges and expenses ; (2) a certificate of insanity from 
one or more respectable physicians ; (3) certain prescribed information as 
to the condition of the patient. 

Indigent patients are admitted only after application to the judge of 
the probate court in the county where the patient resides. The judge 
being informed that there is room for the patient at the asylum, must 
call one respectable physician and other witnesses, and, either with or 
without the verdict of a jury, at his discretion, decides the questions of 
insanity and indigence. The physician's certificate of insanity is taken 
under oath. 

If a paying patient, after three months, becomes indigent, and the 
superintendent certifies that he is a fit patient to remain, he may be re- 
tained at the expense of the State, on the certificate of the probate judge 
of his county. 

Indigent patients after two years' residence in the hospital, if they are 
not likely to be benefited by longer treatment, and are not dangerous, 
may be removed by order of the superintendent to the poor-house of the 
county of which they are resident. 

When a person has escaped indictment, or has been acquitted of a 
criminal charge, on the ground of insanity, the court shall ascertain 
whether the insanity in any degree continues ; in which case the court 
shall order the prisoner to be sent to the insane asylum. 

If a person, held in confinement to await trial or for want of bail, 
appears to be insane, the court must make an investigation, call a respect- 
able physician and other witnesses, and, if necessary, a jury. If it is 
proved that the person is insane, the court may discharge him from im- 
prisonment and order his removal to the hospital, where he must remain 

1 Code of Alabama, 187G, ^? 1470-1503, 2753-2760, 2782, 2795-2790, 2802-2S07, 
2894, 2895, 375G, 3758, 3836, 3838, 3843. 



440 APPENDIX — AEIZONA. 

until restored to his right mind. In case of a recovery he is remanded 
to jail. 

Convicts who become insane while serving their sentence, or who are 
insane at the expiration of their term, if found to be suitable patients for 
the insane asylum, may be sent there by the Governor. A convict sent 
to the insane asylum who recovers before the expiration of his term of 
imprisonment must be returned to the penitentiary or discharged, as the 
Governor may order. 



ARIZONA.^ (Territory.) 

Provisions for the confinement and care of all insane persons in each 
county shall be made by the board of supervisors of each county, either 
in the county jail or in such other place as they shall think best. The 
Governor may make contracts for the keeping and treatment of the insane 
in any hospitals in the State of California. 

The probate judge of any county, upon an application under oath, 
stating that a person by reason of insanity is dangerous, shall cause the 
person to be brought before him for examination, shall summon two or 
more witnesses acquainted with the accused, and shall cause to appear 
one or more graduates in medicine who are also reputable practitioners. 
The physician or physicians shall be present during the hearing, and shall 
make a personal examination of the accused, and shall set forth in a 
written statement to be made upon oath : (1) his or their opinion as to 
the insanity of the party charged ; (2) whether it be dangerous to the 
accused, or to the person or property of others, that the accused go at 
large; (3) whether such insanity is, in his or their opinion, likely to 
prove permanent or only temporary. The judge, if satisfied that the 
person is insane and unfit to be at liberty, shall make an order directing 
his confinement. The property of the insane person is applied, so far as 
it will go, to paying the expense of his commitment and maintenance. 

Upon proof that a person confined for insanity is no longer insane or 
dangerous, the probate judge may direct that he be set at liberty. 

The Governor shall appoint some suitable person to visit once in three 
months the asylums in California where there are patients from Arizona, 
to see that they are properly treated, and to direct the discharge of those 
who are sufficiently restored to reason. 

1 Compiled Laws, 1877, U 1193-1203. 



APPENDIX — ARKANSAS. 441 



ARKANSAS; 



Each county of the State is entitled to send to the insane asylum a 
certain number of patients, proportionate to the number of its inhabitants, 
as shown by the last census. 

Patients are committed to the asylum in the following manner : 

(1) Some reputable citizen files with the county and probate judge a 
written statement, certifying that the patient is a resident of the county 
and is, to the best of his belief, insane, and ought to be committed to the 
asylum for care and treatment. This statement is subscribed and sworn 
to before the judge, who also signs it. (2) The judge, at an appointed 
time, hears the testimony of the witnesses produced, and also causes an 
examination to be made by one or more regular practising physicians of 
good standing. Interrogatories, twenty-six in number, touching the 
habits, history, and condition of the patient are prescribed, and the 
physician or physicians are required to obtain answers. A sworn state- 
ment of the result of the examination, including the questions and 
answers, must be made by the physician or physicians and presented to 
the judge. (3) If the judge is satisfied that the person is insane and a 
fit patient for the asylum, he makes his decision in writing. (4) The 
superintendent notifies the judge w^hether there is room in the asylum 
unoccupied. If there is no room, the name of the insane person is 
entered on the register of the asylum, and the patient will be entitled to 
admission as soon as there is a vacancy. (5) If the judge receives w^ord 
that there is room for the patient, he issues an order to the sheriff to take 
the insane person and deliver him to the superintendent of the asylum. 
Any insane person, a citizen of the State, whose estate will not maintain 
himself and his natural dependents, may be admitted to the asylum and 
maintained at the public expense. Insane persons having property may 
be admitted if there be room. 

Patients are classified into three classes: acute, chronic, and probably 
incurable. If the hospital is crowded with patients, a preference is given, 
in the order of admission, to the acute class, and vacancies may be made 
by discharging those who are probably incurable. 

A patient who has not recovered may be discharged and given into the 
care of his guardian, relatives, friends, or removed to such place as 
is provided for his further custody. Such removal is made by the 
sheriff, or his deputy, by the order of the county and probate judge. 
Persons who have not recovered may also be removed by their friends with 
the consent of the superintendent, or by the direction of the board 
of trustees. Patients who have recovered ma}^ be discharged by the super- 
intendent, but notice shall be sent to the county and probate judge, if 
the removal is without his order. 

1 Arkansas T)io-est, 1874, ^^ 302-326, 1227, 1228, 1828, lOGG, 1988, 2001, 2002, 
3488-3539, 4496-4500, 4539. 

Acts of the General Assembly of the State of Arkansas, 1883, pp. 2, 18-26, 150- 
153,182. 



442 APPENDIX — CALIFORNIA. 

The sheriff, of each county, before delivering any patient to the super- 
intendent, shall see that he or she is provided with suitable clothing to the 
amount prescribed. 

Any person attempting to commit a patient in a vray contrary to the 
provisions of the statute, is guilty of a misdemeanor, and liable to a fine 
of not less than ?50 nor more than §300. 

If a lunatic is furiously mad, so as to be dangerous, it shall be the duty 
of his guardian or the person in charge of him, to confine him in a suitable 
place until the next term of the circuit court for the county, which shall 
make such order for the safe keeping of the person as the circumstances 
of the case may require. If there is no person in charge, or if the 
person in charge fails to take care of such lunatic, any judge of a 
court of record, or any two justices of the peace of the county, may 
cause such insane person to be taken into custody and confined until the 
circuit court shall make further order. 

Insane persons at large shall be arrested by any peace officer and taken 
before a magistrate, who shall make such orders as are necessary to keep 
them in restraint until they can be sent by due process of law to the asylum. 

Insane paupers may be taken care of in the poor-house of the county. 

If in a criminal case, in the course of trial, or after trial and before 
judgment, the court shall be of the opinion that there are grounds for 
believing the defendant insane, all proceedings shall be postponed and a 
jury called to inquire whether defendant is of unsound mind. If found 
insane, he shall be kept in confinement in prison or in the county jail, 
or sent to the lunatic asylum until he is restored. If in the opinion of 
the court he is sane, the trial is to proceed or judgment be pronounced as 
the case may be. 

If a person is under sentence of death, and the sheriff is satisfied that 
there are reasonable grounds for believing him insane, he may summon a 
jury to try the question. If the person be found insane, the sheriff shall 
suspend the execution and report the case to the Governor. 

Persons acquitted of crime on the ground of insanity must be so 
reported by the jury in their verdict, and they shall be committed to the 
asylum by the court for further proceedings or for discharge upon their 
recovery, at the discretion of the court. Convicts becoming insane are 
not admitted to the asylum during their term of service, but are treated 
in the penitentiary. 



CALIFORNIA.^ 



Patients are committed to the Stockton Asylum in the following 
manner : Whenever it is made to appear by affidavit to a magistrate of 

1 Codes and Statutes of California, bv Hittell, 1876, Yol. I. §§ 2136-2222; Vol. II. 
II 11,763-11,766, 13,361, 14,367-14,373, 14,221-14,224, 14,582; Vol. III. |^ 14,368, 
14,370, 14,373. Statutes of California, 1881, Chap. ix. ; 1883, Chaps, liv. and 1x1. 



APPENDIX — CALIFORNIA. 443 

the county that any person within the county is so far disordered in his 
mind as to endanger health, person, or property, he issues a warrant di- 
recting that the person be arrested and taken before some judge of a court 
of record in the county for examination. This judge summons two or 
more witnesses from the persons best acquainted with the insane person, 
and at least two graduates in medicine. The physicians must be present 
at the hearing and make a personal examination of the alleged insane 
person. The physicians must, if they believe the person dangerously 
insane, make a certificate stating the fact and showing, as far as possible, 
the nature and duration of the disease, and the age, residence, and con- 
dition of the patient. The judge, if he is satisfied that the person is so 
far insane as to endanger health, person, or property, makes an order 
that he be confined in the Asylum. This order is executed by the sherifi". 
Idiots, imbeciles, and persons affected with delirium tremens are not 
admitted. 

Commitment to the Napa State Asylum is in substantially the same 
manner, except that the application is made to the County Judge or to 
the Probate Judge of San Francisco, who conducts the examination and 
makes the order for commitment. Also, the physicians are especially 
required to ascertain whether the case is of a recent or curable character, 
and whether the insane person is of a homicidal, suicidal, or incendiary 
disposition, so as to be dangerous tg himself or the community. There 
is the same provision as to idiots, imbeciles, and cases of chronic or 
harmless mental unsoundness, and the resident physician is directed to 
return such persons to the county from which they were committed. 

The judge shall inquire into the pecuniary ability of persons committed 
to the Asylum, and, if there is property sufficient to pay charges, the 
judge shall appoint a guardian to take the property and apply it to paying 
for the maintenance of his ward. If the insane person is indigent, but 
has husband or wife, father, mother, or children living within the State 
having means, they shall pay for his support to the extent and in the 
manner prescribed for paying patients. 

If the kindred or friends of a patient make it appear to the judge of 
the court who issued the commitment that they are capable of giving him 
proper care, the judge may issue an order for the removal of such person. 
No other order or application for release shall be heeded by the Trustees, 
except it be the order of a court or judge on proceedings in habeas corpus. 
If it is brought to the knowledge of the judge that a patient so removed 
is not properly cared for, or is dangerous for want of care, he may order 
such patient to be returned to the Asylum. 

Non-residents shall not be supported at public expense in either asylum, 
except temporarily if stricken while travelling in the State. 

The judges authorized to commit persons may send all patients to the 
Napa Asylum until it is filled, but may order transfers to be made from 
one asylum to the other, with the consent of the resident physicians of 
each asylum, the expense of the transfer to be paid by the guardian or 
friends of the patient. 

If doubts arise as to the sanity of the defendant in a criminal case, 
either during trial or before judgment, the court must order the question 
to be submitted to a jury, and must suspend the trial or the pronouncing 



444 APPENDIX — COLORADO. 

of judgment. If the defendant is found insane, the court must order him 
sent to the State Insane Asylum. If he becomes sane, the superintendent 
shall send word to the sheriff and district attorney, who must put the de- 
fendant into custody until he is brought to trial or judgment. 

If a person has been sentenced to death and there is good reason to 
believe that he has become insane, the sheriff, with the concurrence of 
the judge who rendered judgment, may summon a jury to inquire into 
the supposed insanity. The district attorney is to be notified, and is to 
attend the inquisition. If the defendant is found insane, the sheriff must 
inform the Governor, who may, when the defendant becomes sane, order 
execution of the judgment. 

When a convict, in the opinion of the physician, warden, and captain 
of the yard of the State Prison, is insane, they must certify the fact to 
the Governor, who may order the removal of the prisoner to the Insane 
Asylum. If the convict recovers in the Asylum, the warden of the State 
Prison is to be notified, and the convict is returned to the prison, if his 
term of imprisonment has not expired. 



COLORADO.^ 



Until the asylum for the insane now building is ready, lunatic paupers 
are transported to some convenient asylum, either within or without the 
State limits ; the expense to be paid in the first instance by the county 
of which the lunatic is a resident. This expense shall be repaid the 
county out of the State fund. If any relatives of the lunatic, bound by 
law to support him, and having means, are found in the State, the money 
expended is to be collected of them. 

Whenever any reputable person shall file a complaint, duly verified, in 
the county court, alleging that any person is a lunatic or insane person, 
and that he has property, and is incapable of properly managing the 
same, the judge shall order a jury of six jurors to be summoned to try 
the question of sanity. If the jury find that such person is so insane as 
to be unfit to manage his property, the court shall appoint some fit per- 
son to be conservator of his estate. Whenever any reputable person 
files with the county court a complaint that any person is so insane or 
distracted as to be dangerous to himself or others, if allowed to go at 
large, the judge shall issue an order for the apprehension of such person ; 
provided, also, that when any sherifi" or constable shall find any such 
insane person at large, he shall apprehend him without any order of the 
court. The person thus arrested shall be taken forthwith before the 
county court, or judge thereof, and an inquest, by six jurors, shall be 

1 General Laws, State of Colorado, 1877, pp. 602-610. Session Laws of Colorado, 
1879, pp. 11, 87-92; 1881, pp. 130, 141, 142; 1883, pp. 32, 33. 



APPENDIX — CONNECTICUT. 445 

held in the mode above stated. It may be held without delay, if the alleged 
lunatic so elect; otherwise not until at least ten days' notice has been 
given to him, and to a guardian, who shall be appointed for him. Until 
the determination of the inquest, the alleged insane person shall be con- 
fined in the county jail, or other convenient place. If the jury find that 
such person is so insane as to be unfit to go at large, the court shall 
commit him to the county jail or other convenient place; provided that, 
both before and after such inquest, if there is any relative or friend suit- 
able to have the custody of such alleged insane person, the county court 
shall order him to be delivered into the custody of such relative or friend. 
It is provided further that both the above-mentioned complaints may be 
filed at once, and one inquest held to determine both. No inquest shall 
be had as to the lunacy of any person charged with a criminal ofience 
until ten days' notice has been given to the district attorney or other 
prosecuting ofiicer. 

In case any lunatic has no relative or friend who will take care of him, 
the overseer of the poor-house of the county, or such other person as the 
county commissioners may appoint, shall have the charge of the body of 
such lunatic, and shall comfortably support him, at the expense of the 
county, unless there is property in the hands of his conservator. If 
there is such property, the conservator shall pay the expenses. 

If any person shall present to 'the county court an information in 
writing, stating that any person found by it insane has been restored to 
reason, the court shall cause the fact to be inquired of by a jury. If, 
upon such inquest, he is found restored, he shall be set at liberty, and 
his conservator shall return to him his property. 

All money expended by any county for the support or custody of 
lunatics shall be reimbursed to it out of the State fund. 



CONNECTICUT.^ 



When a pauper in any town is insane, a selectman of such town applies 
to the judge of probate of the district where the pauper resides, asking 
for his admission to the insane hospital. The judge shall appoint a re- 
spectable physician to investigate and report the fiicts of the case. If 
the physician is satisfied of the insanity of the pauper, the judge shall 
order the selectman to take him forthwith to the hospital. A part of the 
expense of his support is paid by the town, and the balance by the State. 

When a person indigent, but not a pauper, is insane, any person, on 
his behalf, may apply to the judge of probate, who shall appoint a 
respectable physician and a selectman of the town where the insane 

» General Statutes of Connecticut, 1875, pp. 19, 20, 25, 50, 90-100, 5;>(). 537. 
Public Acts of Connecticut, 1875-1880. pp. 25, 248, 249, 254, 327, 328, 342, 424, 
452; 1881, pp. 10, 11; 1882, pp. 193, 222; 1883, p. 255. 



446 APPENDIX — CONNECTICUT. 

person resides, to investigate the case and report. If the judge is satisfied 
that the person is indigent and insane, he shall order him to be taken to 
the hospital by the person making the application. Half the expense of 
his support shall be paid by the town and half by the person making the 
application. 

The judge shall make a record of his orders for admission, and shall 
send copies of them to the Governor. 

Paying patients, also, may be committed to the hospital by the super- 
intendent, under special agreements, and comformably to law, when there 
are vacancies. Any sum paid by a town for the support of an insane 
person may be recovered from such insane person or out of his estate, if 
any ever comes into his possession. An insane person may be put in any 
suitable hospital, retreat for the insane, asylum, or place of detention, by 
the relatives, friends, or guardian, on the presentation of a sworn certifi- 
cate, made within thirty days, signed by some reputable physician, stating 
that he has made a personal examination within a week prior to the date 
thereof, and that such person is insane. This certificate and the char- 
acter of the signer shall be certified by an ofiicer authorized to administer 
oaths. Any person thus confined may be removed by the person causing 
him to be detained. 

On a written complaint to any judge of the Superior Court that a person 
is insane, and unfit to go at large, the judge shall appoint a committee, 
consisting of a physician and two other persons, one of whom shall be 
an attorney-at-law, judge, or justice of the peace, who shall examine into 
the case, and report to the judge the facts and their opinions thereon. 
If, in their opinion, such person should be confined, the judge shall issue 
an order therefor. 

Any dangerous insane person at large may, by order of a justice of 
the peace and the first selectman of the town, on the certificate of a 
respectable physician of such town, be confined in some suitable place. 
If the person under whose care he shall be, or who is bound to support 
him, shall not so confine him, he shall be ordered to a suitable place by 
the justice and selectman. 

When any insane person is at large in any town, any person may 
complain to any selectman or justice of the peace of the town, and if he 
do not within three days provide for the confinement of such insane 
person in the manner above stated, the complainant may complain in 
writing, under oath, to any justice of the peace in the town, and such 
justice shall thereupon order a constable to bring such insane person 
before some justice of the peace residing in the town, who, if finding that 
such insane person is unfit to go at large, may order him to be confined in 
some suitable place for such time as he deems proper. But he may at 
any time, for just cause, order his discharge. And the Superior Court, 
on the petition of any person so confined, or of his relatives, the town to 
which he belongs being made a party respondent, may make any proper 
order with respect to his future disposal. All expenses are to be paid 
out of the estate of the insane person, if he has any ; if not, by his 
relatives liable by law to support him ; and if none such, by the town 
where he belongs. 

Persons in charge of any place of detention for the insane may dis- 



I 



APPENDIX — CONNECTICUT. 447 

charge persons placed therein, other than criminals and such as have 
been sentenced, at their pleasure. 

The Board of Charities, consisting of three men and two women, ap- 
pointed by the Governor and removable at his pleasure, shall inspect all 
institutions in which persons are detained by compulsion, to ascertain 
whether inmates are properly treated, and whether any have been unjustly 
placed or are improperly held therein. The insane asylums shall be visited 
as often as once a month. 

Any judge of the Superior Court, on information to him that any 
person is unjustly deprived of his liberty by being detained in any insane 
asylum, or in any place for the confinement of the insane, or in any in- 
ebriate hospital, in the State, may appoint a commission of not less than 
two persons, who shall fix a time for a hearing, and shall have one or 
more private interviews with the person confined, and shall make due 
inquiries of the physicians or other persons having him in charge, and 
shall make a report to the judge of the facts and their opinion thereon. 
If, in their opinion, the party is not legally detained, or is cured, or his 
confinement is no longer beneficial or advisable, the judge shall order his 
discharge. But no commission shall be appointed as to one person oftener 
than once in six months. 

Any superior court, city court, or police court, before which a person 
is tried on a criminal charge, and acquitted on the ground of insanity, 
may order such person to be confined in the Connecticut Hospital for the 
Insane for such time as such court shall direct, unless some person shall 
give bond to the State to confine such person in such manner as the court 
shall order. If the insane person has any property, the court shall ap- 
point an overseer with the powers and duties of a conservator. If he has 
no estate, the expense shall be paid by the town to which he belongs ; if 
he belongs to no town, then by the State. Any person thus confined, or 
the officers of the Hospital, may petition the Superior Court of the county 
in which he is confined for his enlargement. The selectmen of the town 
to which he belongs shall be served with notice, and the State's attorney 
for such county shall appear, and the court shall make such order as it 
shall deem proper as to his disposal. 

If a person confined in jail upon the commitment of a justice of the 
peace is thought to be insane, or an idiot, the county commissioners shall 
appoint a reputable physician to make an examination. If the physician 
is of opinion that the prisoner is insane, or an idiot, he shall make a 
certificate to that effect and deliver it to the commissioners. The com- 
missioners may notify the selectmen of the town where the prisoner 
belongs, and they shall forthwith remove the prisoner from the jail, and 
provide for him in some suitable place. 

Dipsomaniacs, habitual drunkards, and persons addicted to the use of 
narcotics or stimulants, so far as to have lost their power of self-control, 
are treated as lunatics to the extent that the probate court may sentence 
them to an inebriate asylum in the State, for not less than four, nor more 
than twelve months, except that dipsomaniacs shall be committed for 
three years. 



448 APPENDIX — DAKOTA. 



DAKOTA.! (Territory.) 

In each organized county there shall be a board of three commissioners 
call Commissioners of Insanity, two of whom shall constitute a quorum. 
The Judge of Probate is chairman of the board. The other two members 
shall be appointed by the County Commissioners. One shall be a re- 
spectable practising physician, and the other a respectable practising 
attorney. In case of the temporary absence, or inability to act, of two 
of the commissioners, the Judge of Probate may call in a respectable 
physician or lawyer to act with him. 

Application for admission to the Hospital must be made to the Com- 
missioners in writing, sworn to, stating that the person on whose behalf 
the application is made is believed to be insane, a fit subject for treatment 
in the hospital, and living within the county. His legal settlement must 
also be given. The Commissioners shall at once investigate the case. 
They may require the alleged insane person to be brought before them, 
or not, as they deem best. They may provide for the suitable custody 
of the person pending the investigation, and their warrant for the purpose 
shall be executed by the sheriff or any constable. They shall hear testi- 
mony, and any citizen or relative of the alleged insane person may appear 
and oppose the application. Some regular practising physician, who may 
or may not be of their own number, shall be appointed to make a personal 
examination and report whether he finds the person insane or not. The 
physician shall endeavor to obtain from the relatives of the person and 
others correct answers to certain prescribed questions, twenty in number, 
relating to the patient's condition and the nature and duration of the 
disease. The interrogatories and answers are to be attached to the cer- 
tificate which the physician is required to make and give to the Commis- 
sioners. 

If the Commissioners find the person insane and a fit subject for treat- 
ment in the hospital, they issue a warrant authorizing the superintendent 
of the asylum to receive and keep the patient. The sherifi", or some other 
person appointed for the purpose, shall execute the warrant by delivering 
the patient, with a duplicate copy of the warrant and the physician's 
certificate, to the superintendent. If there is any relative or intimate 
friend of the patient who is a suitable person, he shall have the privilege 
of executing the warrant, if he requests it, but shall have no fee for his 
services. No female shall be taken to the hospital without some other 
female or some relative in attendance. 

Patients may have special care in the hospital, if the same is agreed 
upon and paid for in advance. The relatives or friends shall have 
the privilege of paying any portion or all of the expenses of a patient. 

If there is no room for a patient in the hospital, and he is not fit to go 
at large, the Commissioners shall provide for his care, either by a special 

1 Eevised Codes of Dakota. 1877, p. 172. Laws of Dakota, 1879, pp. 68-86 ; 1881, 
pp. 98-102 ; 1883, pp. 298-305. 



APPENDIX — DAKOTA. 449 

custodian to be paid for by the friends or relatives of the patient, or, if 
he is a public patient, they shall require him to be cared for at the 
expense of the county by the commissioners of the county or overseers of 
the poor. If there is no poor-house or more suitable place, the patient 
may be confined in the county jail, or he may be sent to an asylum out 
of the Territory to be designated by the Governor. The commissioners, 
on application made to them, may also make provision in the county for 
the care of persons who are insane, but for whom admission to the hospital 
is not sought. The commissioners, if any insane person in the county 
is suffering from want of proper care, on information of the same, shall 
investigate the matter and make needful provision. Persons cared for 
outside the hospital may be transferred there by authority of the commis- 
sioners, when a vacancy occurs, and without further inquest, when there 
has been an inquest within six months. No person supposed to be 
insane shall be restrained of his liberty except in the way already stated, 
unless it be temporarily to such extent as may be necessary for the safety 
of persons and property, until proper authority can be obtained. Any 
person shall be guilty of misdemeanor who treats an insane person with 
w^anton cruelty. 

If a person, confined in the hospital, is alleged to be not insane, the 
judge of probate, either of the county where the hospital is situated, or 
of the county where the patient has his settlement, upon an application 
alleging that the person is not insane and is unjustly deprived of his 
liberty, shall appoint a commission of not more than three persons, 
of whom one shall be a physician, and, if two or more are appointed, 
another shall be an attorney. They shall make examination and inquiry 
and report to the judge of probate. Such report shall be accompanied 
by a statement of the case signed by the superintendent. If the judge 
on this, and on the testimony offered, is satisfied the person is not insane 
he shall order his discharge. No commission shall be appointed in 
regard to the same party oftener than once in six months. 

If a patient escapes from the hospital, the superintendent shall notify 
the commissioners of insanity of the patient's county, who shall, if he be 
found, have him discharged or returned to the asylum, unless for good 
reasons they have him cared for otherwise. 

Any patient who is cured shall at once be discharged by the superin- 
tendent. The patient, if without means, shall be supplied with clothing 
and a sum of money not exceeding J20, to be charged with the other 
expenses of the patient. A patient who proves incurable, but not dan- 
gerous, may be removed and taken care of by his relatives, with the 
consent of the trustees of the hospital. The friends and relatives of a 
patient who is not cured, and who is dangerous to be at large, may apply 
to the commissioners of insanity of the county where the patient belongs, 
and the commissioners may have the patient removed from the hospital and 
cared for within the county : provided, that no patient under a charge or con- 
viction of homicide shall be discharged without the order of the trustees. 

When patients are discharged from the hospital by the authorities 
thereof, without application therefor, notice shall be sent to the commis- 
sioners of insanity of the patient's county, and they shall provide for the 
care of the patient unless he is discharged as cured. 

29 " 



450 APPENDIX — DELAWARE. 

The expenses of an insane person may be collected by the county com- 
missioners from his estate or from the person legally bound for his support. 

If the hospital becomes crowded, discrimination shall be made in the 
reception of patients in the following order : (1) For cases of less than 
a year's duration. (2) For cases with favorable prospects of recovery. 
(3) For those for whom application has been longest on file. (4) Other 
things being equal, for the indigent. 



DELAWARE.^ 

There is no State insane asylum in Delaware. Insane persons are 
cared for in the county almshouse, or in some asylum in Pennsylvania 
selected by the Governor. 

Indigent lunatics or insane persons are removed to a Pennsylvania 
hospital in the following manner : Whenever the relatives or friends of 
an insane person apply to the Chancellor of the State, and present a cer- 
tificate of two practising physicians of the county where the insane 
person resides, setting forth the insanity, the cause, if known, and the 
necessity of better medical treatment than can be afforded in the county 
almshouse, the Chancellor shall, if satisfied of the insanity and indigency, 
recommend in writing to the Governor that such indigent insane person 
be removed to some asylum in Pennsylvania. But each county shall be 
entitled to have only five patients so supported at any one time. The 
expense of such support shall be paid for by each county. 

When a patient thus placed is cured, or is so far recovered as to be fit 
for removal, or for one year has shown no marked improvement, the 
principal physician of the hospital shall so represent in waiting to the 
Governor of Delaware. Thereupon, the Governor shall make a written 
request for the patient's discharge. 

The Governor shall request a detailed report annually from the asylum 
respecting the condition and treatment of the insane from Delaware, and 
shall transmit it to the legislature. 

If any patient thus placed in a hospital becomes entitled to any 
property, the income of which is sufficient for his support, the Chancellor 
shall appoint a trustee to take charge of the same. The Chancellor may, 
in his discretion, require that such insane person be retained in the asylum, 
paying his own expenses. 

The trustees of the poor of the several counties, on the recommendation 
of the Chancellor and of the resident associate judge, shall cause any of 
the insane poor of their county, whether in or out of the almshouse, to be 
removed to any hospital for the insane in the United States, and they 

1 Laws of Delaware, Revised Code, 1874, pp. 25, 08. 233, 239, 240, 242-244, 650. 
Laws of Delaware, 1875, pp. 103, 104; 1881, p. 411. 



APPENDIX — FLOKIDA. 461 

shall make contracts for their admission and support. The expenses 
shall be paid in whole, or in part, by the said trustees, so long as they 
judge proper. If the insane person has any property, it shall be applied 
to defraying the expenses of his support, whether in the almshouse or 
elsewhere. 

The overseer of the almshouse in each county shall receive and safely 
keep all insane persons committed to his charge by order of the levy court. 

When any insane person is confined in jail, the levy court may issue 
an order that he be placed in the almshouse ; and, if the sentence of any 
convict is respited on the ground of insanity, the convict may be removed 
to the almshouse under such order. 

If, in a capital trial, the defendant is acquitted on the ground of 
insanity, the court may, on motion of the Attorney- General, order that 
the defendant forthwith be committed to the almshouse of the county 
where the case is tried, or of the county where the insane person has his 
residence, or the court may order that such person be placed in any 
lunatic asylum in the United States. The court may appoint a trustee 
to contract for his commitment and support. The expenses shall be paid 
by the county where the offence was committed, or w^here the insane 
person has his residence ; but, if such insane person have property, it 
shall be applied to his support. Sucji insane person may be set at large 
by the court of general sessions of the peace and jail delivery of the 
county where the case was tried Avhenever they are satisfied that 
the public safety will not be thereby endangered; or the said court may 
order his removal from such asylum to the almshouse, either of the county 
where the act was committed, or of the county where he resided. 

If a person becomes insane, pending a civil action, the court may 
appoint a guardian ad litem, or the action may be continued by a trustee. 



FLORIDA. 



It is the duty of each judge of the circuit court of the State, on sug- 
gestion that a person is insane, to issue a writ directing the sheriff to 
bring such person before him for examination. If it be found that such 
person is a lunatic or insane, the judge shall make such decree as is usual 
or necessary in such cases. If it appear that such insane person is desti- 
tute, the judge shall order him transported to the Asylum for the Indigent 
Lunatics of the State of Florida for care and custody ; or he may, in his 
discretion, direct the said insane person to be delivered for custody and 
maintenance to any other person, who shall receive not more than §150 
per year for such maintenance. 

1 Digest of the Laws of Florida, 1822-1881, pp. 448, 747-750. Acts and Kosolu- 
tions of Florida, 1883, p. 64. 



452 APPENDIX — GEORGIA. 

The Comptroller, once in every six months, shall forward to the State 
Attorney of each circuit a list of the lunatics in the care of private persons 
in his circuit. The State Attorney shall cause an investigation of each 
case by the grand juries of the several counties, causing each of said 
lunatics to be brought before them. The grand jury shall make a report, 
a copy of which shall be sent to the Attorney-General and to the Comp- 
troller. The Attorney-General, where he deems it proper, shall direct 
the State Attorney to institute proceedings before the judge of the circuit 
court, looking to the change of the custody of the said lunatic, or to his 
final discharge, or to his transfer to the State Asylum. 

The physician in charge of the State Asylum may, when directed by 
the Board of Commissioners of State Institutions, receive into said 
asylum any lunatic, .idiot, or insane person, whose friends, parents, or 
guardians are able and willing to pay for his care and support, at a rate 
to be fixed by the Commissioners. 

When any person tried for an offence is acquitted by reason of insanity, 
and if the discharge or going at large of such insane person shall be 
considered by the court manifestly dangerous, the court shall order him 
committed to jail, or otherwise to be cared for as an insane person ; or 
may give him into the care of his friends, on their giving security for his 
proper care; otherwise he shall be discharged. 



GEORGIA.^ 



The State Asylum is intended for the care of lunatics, idiots, epileptics, 
or demented inebriates. Inmates are divided into four classes : 1. Pay 
or pauper patients, residents of the State. 2. Pay patients, who are 
non-residents. 3. Insane penitentiary convicts. 4. Insane negroes, in 
certain cases. Citizens of Georgia have a preference over non-residents. 

Resident pay patients are admitted upon authentic evidence of lunacy 
according to law, or by a certificate of three respectable practising physi- 
cians well acquainted with the condition of the patient, or a certificate 
from such physicians and two respectable citizens. Pay patients not 
resident in the State are admitted upon authentic evidence of insanity 
from a court having jurisdiction, or upon a certificate from their own 
State like that required in the State of Georgia, together with the certifi- 
cate of the judge having jurisdiction, that the certificates of the physi- 
cians and other persons are genuine and entitled to full credit. 

The court convicting a pauper of insanity shall certify the fact that he 
is a pauper. If he has any means, or becomes entitled to any property, 
it shall be applied, so far as it will go, to defraying his expenses. If 

1 The Code of the State of Georo-ia, 1882. l^ 331(5), 1341-1374, 1658, 1852-1864, 
2735, 4299, 4666, 4673. 



APPENDIX — GEORGIA. 458 

there is any one liable for his support, the amount expended may be 
collected of him. Otherwise he is supported at the expense of the State. 

Upon the petition of any person, on oath, stating that another is liable, 
as being a lunatic, idiot, or person non compos mentis^ to have a guardian 
appointed, or is a fit subject to be committed to the Lunatic Asylum, the 
Ordinary, upon proof that ten days' notice has been given to the nearest 
three adult relatives of such person, or that there is no such relative 
within the State, shall issue a commission directed to any eighteen dis- 
creet persons, one of whom shall be a physician, requiring any twelve of 
them, including the physician, to examine the person and hear witnesses 
if necessary, and make a return to the Ordinary, specifying under which, 
if either, of said classes they find the person to come. If they find him 
within either of said classes, the Ordinary shall appoint a guardian for 
him, or commit him to the Lunatic Asylum. There may be an appeal 
from this finding to the superior court of the county, where the issue shall 
be submitted to a special jury. 

Guardians of insane persons are authorized to confine them or place 
them in the asylum, if necessary for their own protection or the safety 
of others. A guardian wilfully failing to do this, is liable for all injuries 
inflicted on others by his ward. When there is no guardian for an insane 
person, or the guardian, on notice, fails to confine his ward, and any 
person makes oath that such insante person should not longer be left at 
large, the Ordinary shall issue a warrant, and have the insane person 
brought before him on a day specified. Upon an investigation of the 
facts, he may commit such insane person to the Lunatic Asylum, and, if 
necessary, cause him to be temporarily committed to jail until he can be 
sent to the asylum. 

If a patient in the asylum appears to be incurable, but at the same 
time harmless, he may be discharged by the trustees of the asylum, or 
remanded to the care of friends and relatives. Pauper patients shall not 
be discharged without proper clothing and a sum of money necessary to 
carry them to their residence or to the county from which they were 
sent. 

If, before or after admission of a pay patient, resident or non-resident, 
by certificate, the alleged lunatic or his friend or relative makes a demand 
of the superintendent for a trial of the question of lunacy by jury, it 
shall be had without delay, according to law, in the county where the 
asylum is located. The like demand and trial may be had by all patients 
who have been convicted of lunacy, if the person demanding it, being a 
relative or friend, makes affidavit that he believes the alleged cause of 
commitment did not and does not exist, and that the conviction was 
obtained by fraud, collusion, or mistake. The same right exists also 
when there is an affidavit that the cause of commitment has ceased to 
exist, and there is a refusal by the superintendent to discharge. 

Provision is made for the commitment, admission, and care of in- 
ebriates, but only as pay patients. 

Insane negroes, residents of the State, are to be committed upon the 
certificate of the Ordinary as to their condition mentally and pecuniarily. 

Whenever there is an application for commitment, unattended by the 
requisite evidence, the superintendent may receive the person for a rea- 



454 APPENDIX — IDAHO. 

sonable time, provided payment is made in advance for his maintenance. 
If a person who has been once properly received as a patient has been 
absent so long as three months, he cannot be received back again without 
going through the regular process provided by law. 

If a penitentiary convict becomes so afflicted as to be a fit subject for 
the asylum, he shall be received therein upon the direction of the Gov- 
ernor of the State, or, if accompanied with the certificate of the physician 
of the penitentiary, and of the principal keeper thereof, stating the fact. 
Such convict shall pay for his support, if he has means. If he recovers 
before his term of service has expired, he shall forthwith be sent back to 
the penitentiary. 

When a person has been acquitted of a capital crime on the ground of 
insanity, and is committed to the asylum, he shall not be discharged 
except by special act of the legislature. If the crime is not capital, he 
may be discharged by order from the Grovernor. If sentence was sus- 
pended because of insanity, the superintendent of the asylum shall inform 
the presiding judge of the court where he was convicted in case of 
recovery. 

If a convict sentenced to death becomes insane, the sherifi" shall sum- 
mon a jury of twelve men to inquire into the fact. If the jury find him 
insane, the presiding judge of the district shall certify the fact, and the 
convict shall be received into the lunatic asylum. If the patient recover, 
he shall be removed to the jail, and a new warrant for his execution 
issued. 

When the plea of insanity is filed, the court shall cause that issue to 
be first tried by a special jury, and, if found true, the defendant shall be 
committed to the insane asylum, and shall remain there until discharged 
by the general assembly. 



IDAHO.i (Territory.) 

There is no provision as yet for an asylum for the insane in the Terri- 
tory of Idaho. It is made the duty of the board of county commis- 
sioners in each county to take care of, and provide for, the indigent sick, 
idiotic, and insane of the county under the regulations of law. 

Whenever it shall be represented to the probate judge, upon petition, 
under oath, by any relative or friend of any insane person, or of any 
person who is mentally incompetent to manage his property, the judge 
shall cause not less than five days' notice to be given to the supposed 
insane person of the time and place of hearing the case, and shall cause 
such person, if able to attend, to be produced before him at the hearing. 
If, on examination, it appears to the court that the person in question is 
incapable of taking care of himself and his property, the judge shall 

1 Eevised Laws of Idaho, 1874 and 1875, pp. 310-318, 428, 430, 447-449, 526. 
Laws of Idaho, 1881, U 170, 220, 529, 530, 898. 



APPENDIX — ILLINOIS. 455 

appoint a guardian of his person and estate. Every guardian so appointed 
shall have the care and custody of the person of his ward, and the man- 
agement of his estate. 

If, in a capital case, after judgment of death there be good reason to 
suppose the defendant has become insane, the sheriff, with the concurrence 
of the judge who rendered judgment, may summon a jury of twelve 
persons to inquire into the question of the supposed insanity, and shall 
give notice to the district attorney. If insanity be found, the sheriff shall 
suspend the execution until he receives a warrant from the Governor or 
the judge of the court by which judgment was rendered. The Governor 
may appoint a day for the execution of the judgment in case of recovery. 

When an indictment is called for trial, or a person upon conviction is 
brought up for judgment, if there is a doubt as to his sanity, the court 
shall order the question to be submitted to the regular jury, or may order 
a jury to be summoned, in the way above described, to try the question. 
If the jury find that he is insane, the trial or judgment, as the case may 
be, shall be suspended until restoration to sanity; and the court, if it 
deem a discharge dangerous to the public peace or safety, may order a 
commitment to the custody of some proper person, who must detain the 
prisoner until he becomes sane. Upon his recovery, notice must be given 
to the sheriff and district attorney, and the sheriff shall, without delay, 
place him in proper custody until he be brought to trial or judgment, or 
otherwise legally discharged. The expenses of his care and custody shall 
be borne, in the first instance, by the county where the indictment was 
found; but the amount may be recovered back from the estate of the 
defendant, or from any person or place bound to maintain him. 



ILLINOIS.! 

Preference is given to recent and curable cases, and also to patients who 
are violent or otherwise troublesome, when the asylums are crowded. 
The Board of Commissioners of Public Charities shall visit the insane 
hospital and other places where the insane are confined and exercise a 
power of supervision. They may examine persons under oath, and they 
shall report annually to the Governor. 

All patients, residents of the State, may be kept free of charge (each 
county paying for the support of its insane patients). If a patient is 
able and willing to pay for his support, he may do so. If there is room 
in the hospitals, residents of other States may be admitted as patients, 
upon the payment of the cost of their treatment. 

When any person is supposed to be insane, a petition is sent to the 

1 Kevised Statutes of Illinois, Cothran's Annotated Edition, 1881, pp. 197-LMO, 
303, 507, 508, 950-955, 1076. Laws of Illinois, 1881, pp. 151-153. 



456 APPENDIX — ILLINOIS. 

judge of the county court by a near relative or any respectable person for 
proceedings to inquire into the alleged insanity. On the filing of such 
petition, the judge shall have the alleged insane person brought before 
him at a time and place appointed for the hearing of the matter. At the 
time fixed for the trial, a jury of six persons, one of them a physician, 
shall be impanelled to try the case. The jury shall return a verdict 
showing the facts of the case, stating whether the person is insane, and, 
if so, whether fit to be sent to a State hospital. If the person is found 
to be insane, the court shall enter an order for his commitment to a State 
hospital. If the patient is not a pauper, his friends have a choice as to 
the hospital. The clerk of the court shall apply for the patient's 
admission, and, on ascertaining that he can be received, shall issue a 
warrant to the sherifi" or some suitable person (preferring a relative, when 
so desired), ordering the insane person to be conveyed to the hospital. 
The warrant must be endorsed by the superintendent of the hospital, 
acknowledging the receipt of the patient and returned into court. The 
court, if it is necessary, pending the trial or while waiting for admission, 
may make such order as the case may require, for the temporary restraint 
of the supposed insane person, by a sheriff, jailer, or other suitable 
person. Idiots and persons w4th infectious diseases are not admitted 
to the hospitals. 

The judge of the county court is to see that pauper patiients are 
removed from the hospital when required by the trustees. Patients not 
paupers are removed by their friends, who must give bonds to do so 
upon admission. If a patient is not removed as required, the superin- 
tendent may send him to the place from which he came. 

Whenever application is made from a patient not residing in the State, 
if the superintendent is of the opinion that the case is probably curable 
and there is room at the time in the hospital, the trustees may admit the 
patient, taking a bond for the maintenance of the patient, and for his 
removal when required. No person shall be detained in any asylum or 
hospital for the insane without the order of a court of competent juris- 
diction, or the verdict of a jury. 

When any patient shall be restored to reason, he shall have the right 
to leave the hospital at any time, and, if detained contrary to his wishes, 
he shall have the privilege of a writ of habeas corpus on his own appli- 
cation, or on that of some one in his behalf. If a superintendent or 
ofiicer of an asylum improperly receives or detains a patient, he is liable 
to fine not over $500 or to imprisonment for one year, and also by civil 
process for damages for false imprisonment. 

If, upon the trial of a person charged with crime, it appears that the 
crime was committed by the person while insane, and the jury also find 
that the person has not entirely and permanently recovered, the court 
shall cause the person to be taken to a State hospital for the insane, and 
there kept until fully recovered. But if the jury find that the person has 
entirely recovered from such insanity, he shall be discharged from custody. 

A person who becomes insane after the commission of a crime or mis- 
demeanor, shall not be tried during the continuance of the insanity ; and 
if after trial and verdict he becomes insane, judgment shall be arrested. 
If, after judgment and before execution, the defendant becomes insane. 



APPENDIX — INDIANA. 457 

then, in case the punishment be capital, the execution thereof shall be 
stayed until the recovery of the person from the insanity. In all these 
cases, the court shall impanel a jury to try the question whether the 
accused be at the time insane. 

If a convict in the penitentiary becomes insane, he shall be removed to 
a State hospital for the insane. If he recovers before his term of 
imprisonment has expired, he shall be returned to the' penitentiary. 



INDIANA.^ 

Patients are entitled to treatment, at the expense of the State, in the 
State asylums ; but county asylums may also be provided by the county 
boards. Before commitment, a respectable citizen of the proper county 
shall, upon oath, make a statement, in writing, before a justice of the 
peace of the county, answering as fully as possible twenty-two prescribed 
interrogatories in regard to the alleged insane person's condition and 
history. The justice, together with another justice of the peace, and a 
respectable practising physician who resides in the county, and is not the 
medical attendant of the alleged insane person, shall immediately visit 
and examine the patient in relation to his mental condition. The justice 
of the peace shall then order the clerk of the circuit court of the county 
to summon the regular medical attendant of the patient, if there be one; 
also the person making the statement, and the persons mentioned by him 
in his statement as witnesses; also the selected medical examiner, and 
any other persons supposed to be cognizant of facts relating to the case. 
A hearing shall then be had, the two justices of the peace presiding. 
The medical attendant shall make, on oath, a written statement of the 
case. The medical examiner shall also make a statement, in writing, 
under oath, in prescribed form, saying that he has heard all the evidence, 
and that, in his opinion, the person is, or is not, insane. The justices of 
the peace shall then make a statement, in writing, if, in their judgment, 
the person is insane, and a fit subject for treatment in an asylum. The 
papers and statements are all filed with the clerk of the circuit court of 
the county, who forthwith applies to the superintendent of the Hospital 
for the Insane for the admission of the patient, accompanying the appli- 
cation with certified copies of the statements and certificates, unless the 
proper friends of the insane person prefer to place him in a private 
asylum within the State, when a written permission, under the seal of 
the court, shall be given them to do so, at their own expense. 

The superintendent of the hospital, on receiving the application of the 
clerk, shall determine from the same whether the case is recent and pre- 

1 Kevisod Statutes of Indiana, 1881, ^^ 190, 1107, 1704, 1765, 11758-2782, 2885-2879, 
5142-5150, (5387. Acts of Indiana, Downey's edition, 1883, pp. 1651 , 1652, 1749-1752. 



458 APPENDIX — INDIANA. 

sumably curable, or chronic and less curable, or idiotic and incurable. If 
the case is recent and curable, the superintendent shall grant admission; 
if the case be chronic, whether curable or incurable, admission shall be 
granted, provided there be room. In the selection of chronic cases, each 
county is to have its due proportion, according to its population, and 
priority of application shall also be considered. Rejected applications 
may be renewed at any time within six months from the date of the 
inquest. No idiots are received or kept in the hospital. The clerk of 
the circuit court, on receiving notice that the patient will be admitted, 
shall have him taken to the hospital by the sheriff, or, if so desired, by 
some suitable person w4io shall be a friend or relative of the insane person. 
The clerk shall see that there is a proper supply of clothing for the patient, 
and, if the same is not otherwise furnished, it shall be paid for by the 
county, as also the funeral charges, if the patient dies at the hospital. 
Until the patient can be admitted into the hospital, the clerk shall have 
him taken care of, and, if necessary, may direct his confinement in the 
county jail. 

Patients restored to health are discharged by the superintendent. In- 
curable and harmless patients shall be discharged when it is necessary to 
make room for recent cases ; but all dangerous persons must be retained 
in the hospital. The clerk of the circuit court of the county from which 
the patient was sent, on notice that a patient not restored is to be dis- 
charged, shall issue a warrant to the sheriff to remove the patient to the 
proper township. Patients may be discharged, uncured, to such friends 
as are ready and able to take them. 

A patient once admitted to the hospital, or to any asylum in the State, 
and discharged, shall not be again admitted, except upon the affidavit of 
a respectable practising physician of the county where the patient resides 
that he knows the patient; that he has been adjudged insane; that he has 
been in a hospital; that he is insane, and a proper subject for treatment. 
He must state the reasons for his opinion. The clerk of the court shall 
also make a certificate that the adjudication of insanity is recorded in his 
office. Certified copies of these certificates will serve for an application 
for admission to the Hospital for the Insane or to a private asylum. If 
a person has been adjudged insane, and has not been admitted to the 
hospital within six months from the date of the inquest, the same pro- 
ceedings as in the case of a recommitment must be had. A transcript 
of the papers filed at the inquest must be sent to the superintendent, 
unless previously transmitted. 

Any person committed as insane may have a writ of habeas corpus 
issued, but not oftener than once in three months. 

When a patient is discharged as cured, the superintendent shall furnish 
him with clothing and a sum of money not exceeding $20, unless other- 
wise supplied. 

When complaint on oath is made before any justice of the peace that 
any person is insane and dangerous to the community if allowed to re- 
main at large, such justice shall issue a warrant for the apprehension of 
said insane person, and shall summon such witnesses as may be demanded 
by either party. The justice shall summon a jury of six reputable 
householders, in no way related to, or personally interested in, the 



APPENDIX^ — IOWA. 459 

alleged insane person or his affairs, who shall be sworn to impartially try 
the issue. If the jury, after hearing the evidence and examining the 
alleged insane person, who is to be personally present at the trial, finds 
that he is insane and dangerous to the community if suffered to remain 
at large, the justice shall appoint some resident of the county to take 
charge of and confine him. The person in charge shall be paid by the 
county, and may be changed by the county commissioners, or, if the 
patient is ill-treated, by the justice of the peace. The proceedings of the 
jury and justice of the peace must be reported to the circuit court, and 
at the next term thereof the issue shall be tried again by a jury of twelve 
persons. If they also find the person insane and dangerous, the court 
shall confirm the appointment of the person in charge of the insane 
person, or appoint some one in his place. Such insane person may be 
sent to the Hospital for the Insane, if a fit subject therefor. The cost 
of adjudging such a person insane and of caring for him shall be paid 
out of his property, if he has sufficient ; otherwise by the county. The 
court shall appoint a guardian to care for such property as is subject to 
the payment of his expenses. If the jury before the justice of the peace 
find in favor of the alleged insane person, any one may appeal to the 
circuit court on giving a prescribed bond. 

When a person tried for a public offence is acquitted on the sole ground 
that he was insane at the time the offence was committed, the fact of in- 
sanity shall be found by the jury or by the court, and the defendant shall 
not be discharged, but shall be proceeded against upon the charge of 
insanity, in the manner prescribed for the commitment to the hospital, 
except that no preliminary statement in writing shall be required. 



lOWA.^ 

There shall be in each county a board of three commissioners of 
insanity, including the clerk of the circuit court, who shall be clerk 
of the board. The other two shall be appointed by the judge of the 
circuit court, and shall be, one of them a respectable practising physician, 
and the other a respectable practising lawyer. Temporary vacancies in 
the board may be filled either by the judge of the circuit court, acting as 
a commissioner, or by the appointment of a physician or lawyer. The 
commissioners have cognizance of all applications for commitment to the 
hospital, or for the safe keeping of insane persons, except in cases other- 
wise specially provided for. Applications for commitment to the 
hospital must state upon affidavit that the person is believed by tlie 
informant to be insane and a fit subject for treatment in the hospital, and 
must include information as to his legal settlement. The commissioners 

1 Revised Code of Iowa, Miller, 1880, pp. 874-389; p. 1088, ^ 447*2; p. 1044, ^ 4o04, 
4605; pp. lOGl, 1002. Acts and Kesolutions, State of Iowa, 1882, pp. 58, 84. 



460 APPENDIX — IOWA. 

may examine the informant under oath, and, if they find there is cause 
therefor, may proceed to an investigation. They may have the alleged 
insane person brought before them, if advisable, and may provide for his 
suitable custody pending the investigation. They shall hear such testi- 
mony as is offered for and against the application, and shall appoint some 
regular practising physician of the county to make a personal examina- 
tion of the patient and report thereon. He may, or may not, be of their 
own number. He shall make a statement certifying whether or not he 
finds the person insane, and, as a part of his statement, shall obtain, so 
far as is possible, correct answers to twenty prescribed interrogatories 
touching the condition and history of the patient. 

The commissioners shall make a finding whether or not the person is 
insane and a fit subject for the hospital, and where his legal settlement 
is, if ascertained. If the case is a proper one, they shall order the 
person to be committed to the hospital, unless an appeal from their 
decision is taken to the circuit court. If an appeal is taken, the person 
shall be discharged from custody pending the appeal, unless the commis- 
•sioners find that the person cannot with safety be allowed to go at large, 
in which case they shall provide for his care. If, upon the trial in the 
circuit court, the person is found to be insane, the court shall order him 
to be committed to the hospital. If there is no appeal, or if, on appeal, 
the patient is ordered to be committed, a warrant shall issue, in the one 
case from the commissioners, and in the other from the clerk of the 
court, and the sherifi" or some person appointed shall deliver the patient to 
the superintendent of the hospital, and along with him the physician's 
certificate and the finding of insanity. If any relative or friend who is 
a suitable person request it, he shall have the privilege of executing the 
warrant. If the patient is a female, there must be some other female or 
some relative in attendance. The superintendent shall acknowledge the 
receipt of the patient by a return of the warrant, which shall then be 
filed in court. 

If any person found to be insane and a fit patient for the hospital 
cannot at once be admitted for want of room, or for other cause, the 
commissioners shall have such patient suitably provided for otherwise, 
either as a private or a public patient. Those shall be treated as private 
patients whose friends or relatives will provide for them without public 
charge. In such cases the commissioners shall appoint some suitable 
person a special custodian to restrain and care for the patient. In the 
case of public patients, care shall be provided by the board of supervisors 
at the expense of the county. If there is no poor-house or more suitable 
place, such patients may be confined in the county jail in charge of the 
sherifi". The commissioners may also provide for the care and restraint 
within the county of insane persons, either public or private, for whom 
admission to the hospital is not sought. On information that any insane 
person is suffering for want of proper care, the commissioners shall make 
inquiry and, if need be, provide for the case. Persons who have been 
cared for outside of the hospital may, at any time within six months after 
the inquest, be transferred to the hospital simply on application, unless 
the commissioners deem further inquest advisable. 

On the application of the relatives or friends of an insane person in 



APPENDIX — IOWA. 461 

the hospital, who is not cured, the commissioners may authorize his dis- 
charge if proper provision is made for his care, but no one under a 
criminal charge or conviction shall be discharged without the order of the 
district court and notice to the district attorney. If an insane person 
cared for within the county out of a hospital is shown to be no longer in 
need of care or restraint, the commissioners shall order his immediate 
discharge. Any patient in the hospital who is cured shall be immediately 
discharged by the superintendent, who shall furnish him with suitable 
clothing and money not exceeding J20, unless he is otherwise supplied. 
The relatives of any patient who is found incurable, but not dangerous, 
may take charge of and remove him with the consent of the board of 
trustees of the hospital. 

The trustees, whenever it is necessary to make room, may order the 
removal of incurable and harmless patients, and the commissioners of the 
counties where they belong shall at once provide for their care. 

If for want of room, or for other cause, it becomes necessary to dis- 
criminate in the reception of patients, a selection shall be made in the 
following order: (1) Recent cases (of less than one year's duration). 
(2) Chronic cases (of more than one year's duration), presenting the 
most favorable prospects of recovery. (3) Those for whom application 
has been longest on fde. (4) Other things being equal, the indigent. 

If a patient escapes, the superintendent shall cause search to be made, 
and shall notify the commissioners, who, if the patient is found, shall have 
him returned. 

Each county shall pay the expenses of its own patients, and the State 
shall pay for patients who have no settlement. Patients in the hospital 
may receive special care, if their friends make an agreement with the 
superintendent and pay for the same. The relatives or friends of any 
patient in the hospital shall have the privilege of paying any portion or 
all of the expenses of such patient. If an insane person has property, 
his estate is liable for his support, but the board of supervisors, ijp they 
deem it a hardship to take such estate, may forbear to do so, to such 
extent as they think just and reasonable. 

There shall be a visiting committee of three persons, of whom at least 
one must be a woman, who shall have full power to visit the hospitals, 
send for persons, examine witnesses under oath, discharge or prosecute 
employes for cause, and correct abuses. Inmates shall be allowed to 
write to this committee once a week and to receive letters from them, and 
the same shall not be opened by the superintendent or other officers. The 
committee shall annually report to the Governor. 

If it is alleged on oath that a patient is not insane and is unjustly 
deprived of his liberty, the judge of the district or circuit court of the 
county in which the hospital is situated, or of the county in which the 
patient has his settlement, shall appoint a commission of not more than 
three persons, one of whom shall be a physician, and, if two are appointed, 
one a lawyer. They shall go to the hospital, see the patient and examine 
the records and the officers, in such a manner as they deem most prudent. 
They shall then report to the judge the result of their inquiries, and 
shall get for him a written statement of the case made by tlu^ superin- 
tendent. If the judge finds the person not insane, he shall order his 



462 APPENDIX — KANSAS. 

discharge. This commission shall not be repeated oftener than once in 
six months in regard to the same party, nor appointed within six months 
of the time of the patient's admission. 

If a person charged with a crime, or under indictment, is found by the 
commissioners to have become insane, and to be still insane, they shall 
have him sent to the hospital to be kept by the superintendent. When 
any such lunatic is restored, he shall be again returned to jail to answer 
to the offence alleged against him. 

If a defendant be acquitted on the ground of insanity, the court must, 
if his discharge is considered dangerous to the public, order him to be 
committed to the insane hospital, or retained in custody, until he becomes 
sane. 

If a person, after conviction of a crime, becomes insane, the Governor 
may pardon such lunatic, or may suspend execution of his sentence and 
order his removal to the hospital, there to be kept until restored to reason. 

If a reasonable doubt arises as to the sanity of a defendant, either 
before trial or after conviction, the court must have a jury impanelled to 
inquire into the fact, the other proceedings in the case meantime to be 
suspended. If the jury find the defendant insane, the court, if it deems 
his discharge dangerous, may order his commitment to the insane hospital. 
If he there recovers, he shall again be put in the proper custody until 
brought to trial or judgment, or legally discharged. Any person who in 
any way treats an insane person with wanton severity, or harshness, or 
cruelty, or abuse, shall be guilty of a misdemeanor, and shall be liable to 
an action for damages. 



KANSAS.^ 



The superintendent of one of the two asylums in the State is desig- 
nated by the trustees to receive all applications for commitment, and is 
given authority to determine to which asylum the patient shall be com- 
mitted. 

If information in writing is given to the probate court that anyone in 
its county is a lunatic, or a person of unsound mind, or an habitual 
drunkard, and incapable of managing his affairs, the court, if satisfied 
that there is good reason, shall cause the facts to be inquired into by a 
jury. It is the duty of any judge of the probate court, justice of the 
peace, sheriff, coroner, or constable, who discovers a person of his county 
to be of unsound mind, to make application to the probate court, as 
above stated. 

At the time fixed for trial, a jury of six persons, one of them a physi- 
cian in regular practice and good standing, shall be impanelled, and the 

' Compiled Laws of Kansas, Dassler, 1879, pp. 61, 108-111, 529-537, 584, 762,763, 
883. Laws of Kansas, 1881, p. 78. 



APPENDIX — KANSAS. 463 

alleged insane person may be represented by counsel. The jury shall 
render their verdict in writing, embodying the substantial facts in a form 
prescribed, and the physician upon the jury shall make a brief medical 
statement of the case, so far as ascertained, and of any other circum- 
stances of importance. The verdict shall be recorded at large by the 
probate judge. If it appear that the person is insane and fit to be sent 
to the insane asylum, the court shall make an order for his commitment; 
if " of unsound mind, or an habitual drunkard, and incapable of managing 
his affairs," it shall appoint a guardian of his person and estate. The 
court may, if just cause appears at any tim© during the term at which 
the inquisition is had, set the verdict aside, and cause a new jury to be 
impanelled to try the case. When two juries concur in any case, the 
verdict shall not be set aside. If it shall be found at any time by the 
court, either with or without a jury, as may seem proper to the court, 
that the person is restored to his right mind, he shall be discharged from 
care and custody. 

If any person, by lunacy or otherwise, shall be furiously mad, so as to 
be dangerous, it shall be the duty of his guardian, or other person under 
whose care he may be, to confine him in some suitable place until pro- 
ceedings can be commenced in the probate court, which shall make such 
order as may be proper for the support and safe keeping of such person. 
If there is no guardian or person in 'charge to care for him, any judge of 
a court of record, or any two justices of the peace, may cause him to be 
apprehended, and may employ some one to confine him until the probate 
court shall make some order in regard to him. 

When a probate judge desires to commit an insane person to the State 
Insane Asylum, he shall send a statement, in a prescribed form, to the 
superintendent, inquiring whether the patient can be admitted. Upon 
receiving a reply that the patient will be received, the judge shall issue 
his precept to the guardian, commanding him to deliver his ward into the 
custody of the superintendent, and at the same time give to the steward 
of the asylum a warrant directing him to maintain the patient. The 
warrant states also who is to bear the expenses, whether the county or 
the guardian, or some one else. To determine who is to bear the ex- 
pense, the probate judge shall make an examination of the property, and, 
if he finds that the insane person has no estate, or not more than enough 
to support his family, shall make a certificate to that effect, and the ex- 
pense of his support shall be borne by the county. 

Patients supported at private expense may be placed in the asylum 
upon application to the superintendent, if the case comes within the 
provisions of the asylum by-laws, and if there is room in the asylum. 
In every such case, the superintendent shall be presented with a certifi- 
cate, signed by at least one practising physician of the county, stating 
that he has examined the patient, and believes him to be insane. There 
sliall also be presented a certificate of the probate judge of the proper 
county, stilting that he has appointed some one (naming him) as guardian 
of the patient. Questions as to the history of the case must be filled out, 
and forwarded to the superintendent. 

The person or court placing a patient in the asyluui nu\y remove such 
patient at any time, and the superintendent, under direction of the 



464 APPENDIX — KENTUCKY. 

trustees, may discharge any patient in accordance with the by-laws. No 
idiot or person with a contagious disease shall be committed to the 
asylum. 

Destitute insane persons, who have been refused admission to the 
asylum because of lack of room, are supported at the expense of the 
State. 

When a patient is to be discharged, the probate judge of the proper 
county shall be notified. If he is not restored to sanity, the judge shall 
issue his precept to the guardian of such person to remove him from the 
asylum to the proper county. If he is recovered, the steward may, under 
direction of the superintendent, send him, at the expense of the county 
or person charged with his maintenance. 

If a convict in the penitentiary becomes insane, the warden shall 
notify the prison physician, who shall, if he deem the statement true, 
summon to his assistance the nearest two resident physicians, and pro- 
ceed to make inquisition of the facts charged. If they find the person 
insane, they shall so certify to the warden, who shall cause the insane 
person to be removed to the Asylum for the Insane, there to be kept 
until he recovers, or is discharged by expiration of his sentence, by 
pardon, or by reprieve. If he recovers before his term has expired, he 
shall be returned to the warden. 

In case of a person convicted and sentenced to death becoming insane, 
such person shall not be executed until the Governor shall be satisfied, 
upon the oaths of twelve good and true men, to be named and summoned 
by the warden, upon proper inquiry and investigation being made, that 
such insanity no longer exists. 



KENTUCKY.^ 



Each of the three asylums receives the insane of its own district, but 
patients may be transferred from one to another, in case any one is 
crowded. Negroes shall be sent only to the Eastern and Central Asylums. 
It is the duty of the Governor to see that each asylum has its due share 
of patients. 

If anyone be thought of unsound mind, it shall be the duty of some 
court of the county in which he resides, having general equity jurisdiction, 
upon the application of the attorney for the commonwealth, or, if he be 
absent, of the county attorney, to cause an inquest by a jury to be held 
in open court to inquire into the fact. Inquests may be held by a judge 
or chancellor, by the presiding judge of a county, the judge of a city 
court, or police judge, when no court of general equity jurisdiction is in 
session. The court shall appoint some member of the bar to represent 

1 General Statutes of Kentucky. 1881, pp. 534-541, 642-652. Acts of Kentucky, 
1881, p. 15. 



APPENDIX — KENTUCKY. 466 

the rights of the person alleged to be of unsound mind. It shall also be 
the duty of the attorney for the commonwealth, or for the county, to 
prevent any persons being improperly found of unsound mind. The jury 
shall take a formal oath to find truly whether the person is of unsound 
mind, and, if so, whether he is an idiot, or a lunatic, what his residence 
is, and what property he or his parents have. If the judge who presides 
is of the opinion that the verdict is not sustained by the evidence, or is 
against law, he shall set it aside and award a new inquest. The person 
alleged to be of unsound mind must be in court personally before the 
jury, unless it shall appear by the oath or affidavit of two physicians that 
they have personally examined the person, and that they verily believe 
him to be an idiot or lunatic, as the case may be, and that his condition 
is such that it would be unsafe to bring him into court. Every fifth 
year, in the case of idiots, this inquest must be repeated to ascertain 
whether any change has taken place in their condition. 

All lunatics may be sent by order of the court to the lunatic asylum. 
The officer who presides at the inquest may make all orders for the security 
of the estate and care pending the inquest of the person found of unsound 
mind. The papers pertaining to the inquest shall be filed with the clerk 
of the court having jurisdiction, and, at the next term thereof, a com- 
mittee shall be appointed and such other orders made and taken as are 
necessary. If a person is found a lunatic, the officer who presides at the 
inquest shall draw up a brief history of the patient's case embracing 
certain points which are enumerated in the Statutes. 

If the patient is delivered at the hospital within six months after the 
first attack of his lunacy, and the fact is certified to by the circuit judge 
of the district, neither the county nor any relative shall be chargeable 
with the cost of his detention for one year in the asylum, nor shall a 
relative in such case be chargeable with the cost of his transportation. 

Immediately on notice that a person has been ordered into confinement 
at the asylum the superintendent shall send for him ; but where the safety 
of the lunatic or others seems to require it, the court may order the patient 
to be carried to the asylum immediately without waiting for his being 
sent for. 

Idiots shall not be sent to the asylums, unless the jury find that they 
are so dangerous that they cannot be safely kept by a committee within 
the county. Pay patients from other States may be admitted, but not 
when their reception will in any way crowd the asylums so as to delay 
the reception of patients resident in Kentucky. 

No private patient who has not been found to be insane by regular 
inquest shall be received into either asylum. Nor shall any patient be 
discharged as cured, or delivered into the custody of friends, if his friends 
have placed him in the asylum, except by permit of the superintendent 
and two commissioners. 

A cured pauper, on discharge, shall have a good suit of clothes and be 
furnished with money not exceeding $20. 

In order to relieve the asylum from having too many patients, all 
pauper idiots, epileptics, and harmless, incurable lunatics shall be re- 
turned by the asylum to their friends or to the several counties from 
which they were sent. A commission, consisting of the president of the 

30 



466 APPENDIX — LOUISIANA. 

board of commissioners of each asylum, the superintendent and one other 
of the commissioners, shall investigate and determine what patients are 
fit to send back. Such patients are to be taken care of either by their 
county committee, or by their friends, or at the expense of the State, as 
the case may be. 

Whenever it is suggested by affidavit to the court having jurisdiction, 
that a person found of unsound mind has been restored to his proper 
senses, or that the inquest was false or fraudulent, the court shall forth- 
with direct the facts to be inquired into by a jury in open court and make 
all necessary orders in the premises. 

Any patient charged with crime who is cured of his insanity shall be 
delivered to the keeper of the penitentiary or jailor of the county, as the 
case may require. 



LOUISIANA.! 

Whenever it shall be made known to the judge of the district or parish 
court, by the petition and oath of any individual, that any lunatic or 
insane person within his district ought to be sent to, or confined in, the 
Insane Asylum of the State, said judge shall issue a warrant to bring 
the insane person before him, and, after proper inquiry, if, in his opinion, 
he ought to be sent to the asylum, he shall have him taken there by the 
sheriff. 

The board of administrators of the asylum shall have authority to 
receive insane persons cot sent by a district or parish judge, on such 
terms as they may deem fit, and money so received shall be applied to 
the support of the institution. 

All persons received in the asylum as insane shall be charged not less 
than f 10 a month, unless the police jury of the parish from which the 
insane person came, a municipal council, if from a city or town, or clerk 
of the court, shall certify that said person is in indigent circumstances. 
The clerk of the court, before granting such a certificate, shall summon 
witnesses, and make an examination, and give or refuse the certificate, as 
each case may require. 

Whenever any person arrested to answer for any crime or misde- 
meanor, before any court of the State, shall be acquitted by the jury, or 
shall not be indicted by the grand jury, by reason of the insanity of such 
person, and the discharge of such person shall be deemed by the court to 
be dangerous, the court shall commit such person to the State Insane 
Hospital, or to any similar institution in any parish within the jurisdic- 
tion of the court, there to be detained until restored to his right mind or 
duly discharged. The physician of the asylum shall examine the lunatic 

1 Yoorhies' Revised Statutes of Louisiana, 1876, pp. 427, 462-466. 



APPENDIX — MAINE. 467 

or insane person sent to the asylum by such a judge, and if, in his 
opinion, the person is only feigning insanity, being a person charged with 
a felonious crime, he shall report to the board, who shall investigate the 
facts, and if a majority think he should not be admitted, he shall be sent 
to jail, and the proper authorities notified ; and also if the prisoner is 
received and becomes sane while in the asylum. 

Any person attempting or assisting the seduction or abduction of a 
patient from an insane asylum shall be liable to a fine not less than $50 
and not exceeding $500, or to imprisonment from one to six months, or 
to both, at the discretion of the court. 



MAINE.^ 



The number of patients who can be accommodated in the hospital 
shall be apportioned among the towns according to their population. If 
the hospital is likely to be crowded, a preference shall be given to those 
towns which have not already their full proportion of patients accommo- 
dated. 

The municipal ofiicers of towns shall constitute a board of examiners, 
and, on complaint in writing of any relative or justice of the peace of 
their town, they shall immediately inquire into the condition of any 
person therein alleged to be insane. The evidence, and a certificate of 
at least two respectable physicians, based upon due inquiry and personal 
examination of the person to whom insanity is imputed, shall be required 
to establish the fact of insanity. A certified copy of the physicians' 
certificate shall accompany the person to be committed. If the board of 
examiners think such person insane, and that his comfort and safety, and 
that of others interested, will thereby be promoted, they shall forthwith 
send him to the hospital, with a certificate stating his insanity and his 
residence, and directing the superintendent to receive and detain him. 
The examiners shall keep a record of their doings. 

Any person aggrieved by the decision of the board of examiners, for 
or against insanity, may appeal therefrom, by claiming the appeal within 
five days, naming a justice of the peace and quorum on his part, and 
appointing a time within three days thereafter, and a place in such town 
or an adjoining town for the hearing; the board of examiners shall select 
another justice of the peace and quorum. 

If the municipal officers applied to in the first instance neglect for 
three days to examine into and decide a case, or if the two justices 
selected on appeal neglect for three days to decide the appeal, coni})laint 
may be made by any relative of the insane, or by any res})ectable person. 

* Commissioners' Keport on Revision of the Laws of INIaine. 1881, pp. <iO, OTxl, 1 125. 
1126, 1155, 1163-1173. Special Acts and Resolves, 1883, p. 155. 



468 APPENDIX — MAINE. 

to two justices of the peace and quorum, and the justices selected in 
either of the above modes shall summon testimony, and hear and decide 
the case. If they find the person insane, and the case a proper one, 
they shall make a certificate for his commitment to the hospital. Such 
justices shall keep a record of their doings. When such justices- order a 
commitment, the municipal officers of the town where the insane person 
resides, or such other person as the justices direct, shall attend to the 
carrying out of such order. 

The officers ordering the commitment of a person unable to pay for 
his support may certify to the trustees that fact, and that he has no 
relatives able and liable to pay for it. In such cases the State shall pay 
$1.50 a week for his board, and the balance shall be paid by the patient, 
or by the tow^n where he resides. 

Parents and guardians of insane minors, if of sufficient ability to sup- 
port them in a hospital, shall, within thirty days after an attack of 
insanity, send them to the State Hospital, or to some other hospital for 
the insane, without any legal examination. All other persons shall be 
subject to examination. Any town paying for the commitment and 
support of an insane person may receive the amount from him, if he has 
property, or from the persons legally liable for his support. 

When any man, or any unmarried woman of twenty-one years of age, 
is sent to the Hospital for the Insane, the municipal officers of the town, 
when they think it advisable, may apply to the probate judge, and have 
a guardian appointed to care for any property that he or she may have, 
and provide for the support of the insane person and family. 

Patients who have no means of their own and are without relatives 
liable for their support, if they belong in towns having less than two 
hundred inhabitants, shall be supported in the hospital at the expense of 
the State. 

When any friend, person, or town, liable for the support of a patient 
who has been in the hospital six months, not committed by order of the 
Supreme Judicial Court, nor afflicted with homicidal insanity, thinks 
that he is unreasonably detained, he may apply to the municipal officers 
of the town where the insane person has his residence, and they shall 
inquire into the case and summon testimony, and their decision shall be 
binding on the parties. If such application is unsuccessful, it shall not be 
made again until the expiration of another six months. 

At the annual meeting of the trustees, they, with the superintendent, 
shall make a particular examination into the condition of each patient 
and discharge any one so far restored that his comfort and safety, and 
that of the public, no longer require his confinement. The superin- 
tendent, at each monthly visit of the trustees, shall report to them the 
name of any inmate who was idiotic at the date of his commitment, and 
of any inmate who has become so imbecile as in his judgment to be beyond 
cure, and, if he thinks such inmate may be discharged with safety to him- 
self and to the public, the trustees shall order his discharge, and cause 
him to be removed by the town by which he was committed. If any 
person appears to have been unlawfully committed, the superintendent 
shall report in like manner. 

The Governor shall appoint a committee of visitors, consisting of two 



APPENDIX — MAINE. 469 

members of the executive council and one woman, who shall make visits 
as often as once a month, and shall correspond with the patients, and shall 
report all abuses and ill-treatment, and see that the same are properly 
dealt with. If the committee of visitors shall become satisfied that any 
inmate is wrongly committed or detained, they shall apply to the proper 
court for a writ of habeas corpus, and have the question determined 
whether such inmate is a proper subject for custody and treatment. But 
this shall not apply to the case of any person charged with, or convicted 
of, crime and duly committed by order of court. 

When any person is indicted for an offence, or is committed to jail on 
a charge thereof, any judge of the court before which he is to be tried, 
when he is notified that a plea of insanity is, or will be, made, may order 
such person into the care of the superintendent of the insane hospital, to 
be detained and observed by him until the further order of the court, that 
the truth or falsity of the plea may be ascertained. Every such person 
so committed shall be discharged by the superintendent if recovered, if 
not sent for by the court during the next term thereof after his com- 
mitment. 

When the grand jury omits to indict, or a traverse jury acquits, on 
account of the insanity of the accused, the court may commit the person 
to the insane department of the State Prison, or to the insane hospital. 
If committed to the insane department of the State Prison, he shall be 
discharged only on satisfactory proof that his discharge will not endanger 
the peace and safety of the community. If he is discharged and again 
becomes insane, any judge of the Supreme Judicial Court may recommit 
him to the insane department of the State Prison, or to the insane hos- 
pital. If committed in the first instance to the insane hospital, he may 
be discharged by any judge of the Supreme Judicial Court, if his dis- 
charge will not endanger the community ; or the judge may, on applica- 
tion, commit him to the custody of any friend who shall give bonds to 
the Probate Judge of Kennebec County to keep such insane person safely 
and pay for all damage he may do. If such person again becomes dan- 
gerous, any judge of the Supreme Judicial Court may recommit him to 
the insane hospital. 

When a convict is thought insane, the warden or jailor shall notify the 
Governor, who shall appoint two or more skilful physicians to investigate 
the case. If such inmate is found insane, he shall be sent to the insane 
hospital, to be kept there until he becomes of sound mind. If he recovers 
before the expiration of his sentence, he shall be returned to prison. If 
insane convicts prove incurable and likely to have a deleterious intluence 
on the other patients of the hospital, the Governor and Council may 
remove them to the insane department of the State Prison. 

If an insane person is arrested on civil process, a writ of habeas corpus 
may be had to obtain his discharge. 



470 APPENDIX — MARYLAND. 



MARYLAND. 



Each county is allowed in the insane hospital its due share of inmates 
in proportion to its population. Pay patients, to a number not exceeding 
seventy-five at any one time, may be received. Lunatics and insane 
persons are also provided with accommodations and support in the 
county almshouses, and in the almshouse of the city of Baltimore. A 
court of equity may, on the application of the trustee of a person non 
compos mentis^ if satisfied that it is necessary and proper to confine such 
person, direct that he be sent to any hospital in the vicinity of the city 
of Baltimore, there to remain until the further order of the court. 

AYhen any person is alleged to be a lunatic or insane pauper, the 
circuit court for the county where he resides, or the Criminal Court of 
Baltimore, if he resides there, shall cause a jury of twelve men to be im- 
panelled to inquire whether such person is insane or lunatic. If he shall 
be found so, the court shall cause him to be sent to the almshouse of the 
county or city to which he belongs, or to a hospital, or to some other 
place better suited to his condition, there to be confined, at the expense 
of the county or city, until he has recovered. But the friends or relations 
of such lunatic or insane person are not prevented from confining him or 
providing for his comfort. 

The county commissioners of any county may, in their discretion, re- 
move any lunatic pauper from the almshouse and send him to the Hospital 
for the Insane, and, if the quota allowed such county is already filled, the 
expense of such lunatic at the hospital shall be paid by the county. No 
person shall be supported as a pauper lunatic if he has any property, nor 
shall a person who is living with his parents be so supported if they have 
property assessed as high as $1000. 

Private patients are committed to an asylum, under its by-laws, upon the 
certificate of insanity by a regular physician, sworn to before a magistrate, 
and upon the request of some responsible person, who shall give bonds. 

If a person under indictment or charged with any ofience is alleged to 
be insane or a lunatic, and it is found by the jury who try the case, or 
by a jury summoned to inquire into the insanity, that such person was 
insane at the time of committing the ofi'ence, and still is so, the court shall 
cause such person to be sent to the almshouse of the county or city to 
which such person belongs, to a hospital, or to some other place better 
suited to the condition of the prisoner, there to be confined until he has 
recovered his reason and has been discharged by due course of law. 

If, during the recess of either of said courts, any person appearing, or 
alleged to be, insane shall be arrested and charged with a crime, the judge 
shall have a jury of twelve men at once summoned by the sheriff, to try 
the question whether the prisoner was insane when the offence was com- 
mitted, and still is so. If found insane, he shall be committed as above 
stated. 

1 Pvevised Code of Maryland, 1878, pp. 62, 242-244, 497-499, 660. Laws of Mary- 
land, 1880, p. 465. 



APPENDIX — MASSACHUSETTS. 471 

If any prisoner thus found insane has property, the income of which is 
sufficient to pay for his support in a hospital, the court shall appoint a 
trustee to take charge of such estate and to have such insane person con- 
fined and supported in some hospital or asylum. 

If any convict in the Maryland Penitentiary is insane, the Governor, 
on recommendation of the board of directors, may remove him and 
provide for his support and safe keeping in the Hospital for the Insane, 
or in any other State institution for the insane, and the expense shall 
be paid out of the funds of the penitentiary. 



MASSACHUSETTS.! 

A judge of the supreme judicial court, or superior court, in any county 
where he may be, and a judge of the probate court, or of a police, district, 
or municipal court within his county, may commit to either of the State 
lunatic hospitals any insane person then residing or being in said county, 
who, in his opinion, is a proper subject for its treatment or custody. 

Except when otherwise specially provided, no person shall be committed 
to a lunatic hospital, or other receptacle for the insane, public or private, 
without an order or certificate signed by one of said judges, stating that 
the judge finds that the person is insane and is a fit person for treatment 
in an insane asylum. The judge shall see and examine the person alleged 
to be insane, or shall state in his order the reason why it was not deemed 
necessary. The judge shall in all cases certify in what place the lunatic 
resided at the time of commitment. There must be filed with the judge 
a certificate signed by two physicians, each of whom is a graduate of some 
legally organized medical college, and has practised three years in the 
State, and neither of whom is connected with any hospital for the insane. 
Each physician must have personally examined the person alleged to be 
insane, within five days, and each shall certify on oath that in his opinion 
the person is insane and a proper subject for treatment, giving his reason 
therefor. A copy of this certificate shall be sent with the patient to the 
hospital. 

A person applying for the commitment of a lunatic to a State hospital 
shall first give notice to the mayor, or one of the selectmen of the place 
where the lunatic resides, of his intention to make such application. In 
all cases there shall be filed with the application, or Avithin ten days after 
the commitment, a statement in detail in prescribed form, giving the 
history, habits, and condition, and the names of relatives, not exceeding 
ten in number, of the patient. This statement, or a copy of it, shall be 
sent to the superintendent of the asylum. The superintendent shall at 

1 Public Statutes of Massachusetts, 1882, pp. 432-484, 471, 472, 474-482, 9i\\ 1197, 
1198, 1201, 1202, 1207, 1244. Acts and Resolves of Massachusetts, 1882, p 248: 
1883, pp. 49, 77. 



472 APPENDIX — MASSACHUSETTS. 

once cause notice to be sent by mail to each of said relatives of the fact 
of the patient's admission, and also to any other two persons whom the 
patient shall designate. The judge, in his discretion, may apprehend the 
alleged insane person and place him in confinement pending examination, 
and may summon a jury to try the question of insanity. The verdict of 
the jury shall be final. 

If the State Board of Health, Lunacy, and Charity finds an insane 
person not incurable, in an almshouse or other place, in need of better 
treatment, it shall cause application to be made to a judge for his commit- 
ment to a hospital. 

Any person whose case is duly certified separately by two physicians, 
qualified as above, to be one of violent and dangerous insanity, may be 
received by the superintendent of any lunatic hospital and detained not 
exceeding five days without any w^arrant of commitment by a judge. In 
such a case there shall be an application, signed by one of the selectmen 
of the town, or by the mayor or one of the aldermen of the city where 
the insane person resides, stating that the case is one of violent and 
dangerous insanity, and giving the facts in regard to the patient's 
symptoms and history. The person committing such a person shall give 
a bond of $100 dollars that he will, in five days, obtain a regular order 
of commitment, or take the patient away. 

The superintendent of any insane hospital, private or public, may 
receive and detain therein as a boarder and patient any person who is 
desirous of submitting himself to treatment, and makes written applica- 
tion therefor, but who is not so insane as to make it proper to grant a 
certificate of insanity. Such patient shall not be detained longer than 
three days after having given notice in writing of his desire to le^ve. 
When such a patient is admitted, notice shall at once be given to the 
State Board of Health, Lunacy, and Charity, who shall cause the case to 
be investigated. 

Pauper lunatics having no known settlement shall be supported at the 
expense of the State ; other pauper lunatics by the towns or cities where 
their settlement is. Amounts paid by the State, or by a city or town, 
may be recovered of any person legally liable to support the lunatic. 

The attorney of a patient shall be allowed to visit him in the hospital 
at all reasonable times, if his visits, in the opinion of the superintendent, 
would not be injurious to the patient, or upon the order of a judge of the 
supreme, superior, or probate court. Patients shall be furnished materials 
to write monthly to the superintendent and to the State Board ; and 
locked letter-boxes shall be provided in each ward, to be opened monthly 
by the State Board. 

The State Board of Health, Lunacy, and Charity, shall have general 
supervision over the hospitals for the insane, public and private, and 
shall act as commissioners of lunacy, Avith power to discharge any person, 
whether insane or not, who is improperly restrained of his liberty, in 
their opinion, by reason of alleged insanity. It may discharge also such 
patients as can be cared for after such discharge without danger to others 
and with benefit to themselves. The Board may, when directed by the 
Governor, assume and exercise the powers of the board of trustees. 

Any two of the trustees of a State lunatic hospital, or any judge of the 



APPENDIX — MASSACHUSETTS. 473 

supreme judicial court, or the judge of the probate court for the county 
in which the hospital is situated, or in which the patient had his resi- 
dence, after such notice as the said trustees or judge may deem reason- 
able and proper, may discharge any patient, if it appears that he is not 
insane, or, if insane, will be sufficiently provided for by himself, his rela- 
tives, or friends, or by the city or town liable for his support, or that his 
confinement is no longer necessary for the safety of the public or his 
own welfare. Any two of the trustees may remove to the town or city 
from which he came any patient who is incurable and is not dangerous. 

Any person may apply to a judge of the supreme judicial court, stating 
that he has reason to believe that a person named is confined as insane 
in a lunatic hospital, or other place, public or private, and ought not 
longer to be so confined, and requesting his discharge. Such judge, if 
he thinks it proper, shall appoint a hearing and give notice of it to the 
superintendent, and to such other persons as he deems proper. The 
alleged insane person may be brought personally before the judge by a 
writ of habeas corpus, if it is requested, and he thinks it proper. On 
the request of any person interested, the question shall be submitted to 
a jury. If it is found by the jury, or by the judge if it is not submitted 
to a jury, that the person is not insane, or ought not to be so confined, 
he shall be discharged from such confinement. 

No pauper shall be discharged from a State hospital without suitable 
clothing, and the trustees may furnish him with a sum of money not ex- 
ceeding $20. 

The Governor or the State board may transfer inmates from one State 
hospital to another when it is necessary or advisable. 

The State board also may remove any inmate of the State Almshouse 
or State Workhouse to either of the State lunatic hospitals, if his condi- 
tion requires such transfer. But no such transfer shall be made without 
the certificate of two physicians, one of whom has no connection with any 
insane hospital, to the insanity of such inmate. 

Transfers from one private asylum to another, or from a private asylum' 
to a State lunatic hospital, may be made with the consent of the State 
Board, but no such transfer shall be made without the consent of the 
legal or natural guardian of such inmate. 

If all the State lunatic hospitals are crowded, the trustees of any one 
may remove to their homes, or places of legal settlement, so many of 
those who are incurable and can be suitably managed at home as may be 
necessary to make sufficient room. 

Patients not furiously mad may be committed by any judge authorized 
to act to the county receptacle, which is required by law for each county, 
either within the precincts of the house of correction, or in another 
building to be deemed a part of the house of correction. 

Any insane person confined in a jail, house of correction, or county 
receptacle, may be removed by the Governor to either of the State 
lunatic hospitals, or to any other jail, or to any other suitable place, 
whenever it seems expedient and just. 

Any person committed to a county receptacle as not furiously mad 
may be discharged by the judge, if it appears to be for the patient's 



474 APPENDIX — MASSACHUSETTS. 

benefit, or when it appears that he can be comfortably cared for by friends 
or kindred. 

Dangerous lunatics shall not be sent to the State Almshouse. 

The board of trustees of any of the State lunatic hospitals may give 
the superintendent authority to discharge any inmate committed thereto, 
as an insane person, but notice of the intention to discharge must be sent 
by the superintendent to the person or persons who signed the petition 
for the commitment of such inmate. The superintendent may also, if 
he deem it advisable, allow inmates to leave the hospital temporarily in 
charge of their friends for a period not exceeding sixty days, and may 
receive such patients back without any further order of commitment. 

When a person confined in jail on civil process is supposed to be in- 
sane, so as to be incapable of taking the poor debtors' oath, any person 
interested may apply to the judge of probate for the county in which he 
is imprisoned. The judge shall appoint a hearing, give notice to the 
creditor or his attorney, and proceed with an examination into the ques- 
tion of insanity in the regular manner. If the person is found insane, 
the judge may order his discharge, or his removal to one of the State 
lunatic hospitals, or other place, for the confinement of insane persons. 

If the grand jury fail to indict a man by reason of his insanity, the 
court, or a judge of the supreme court, sitting for the arraignment of a 
person charged with murder, if satisfied that he is insane, may order him 
to be committed to a State lunatic hospital. 

When a person indicted is at the time appointed for the trial found to 
the satisfaction of the court to be insane, the court may cause him to be 
removed to one (5f the State lunatic hospitals. 

If a person convicted of a capital crime, but not yet sentenced, is found 
to the satisfaction of the court to be insane, he may be removed to one of 
the State lunatic hospitals. 

If a person convicted and sentenced to death appears to the satisfac- 
tion of the Governor and Council to have become insane, they may respite 
the execution from time to time, until it appears that the convict is no 
longer insane. 

A person acquitted of a crime, other than murder or manslaughter, by 
a jury on the ground of insanity, may be committed to an insane asylum 
by the court, if satisfied of the insanity. 

When a convict in the State Prison or Woman's Reformatory Prison 
appears to be insane, he may be removed, by order of the Grovernor, to 
one of the State lunatic hospitals. Such convict, however, shall first be 
examined by a person expert in cases of insanity appointed by the State 
Board of Health, Lunacy, and Charity, and also by the physician of the 
prison. 

If he recovers his sanity before his term of imprisonment has expired, 
he shall be reconveyed to the prison. 

When a convict in a house of correction or prison other than the State 
Prison or Reformatory Prison appears to be insane, the case shall be 
reported by the physician to the jailer or keeper, and by him to one of 
the judges authorized to act in cases of insanity, and the regular pro- 
ceedings shall be had for committing such person to an insane hospital. 



APPENDIX — MICHIGAN. 475 

If he recovers before the expiration of his sentence, he shall be returned 
to the prison or house of correction. 

Persons held in jail for trial or for sentence, except for a capital crime, 
may, if found insane, be committed to one of the State lunatic hospitals, 
there to remain until restored to sanity. 

When a person indicted for murder or manslaughter is acquitted by 
reason of insanity, the court shall order such person to be committed to 
one of the State lunatic hospitals during his life. He may be discharged 
therefrom by the Governor, with the consent of the council, if he becomes 
no longer dangerous. 

Any physician wilfully conspiring to commit any person who is not 
insane to any hospital or asylum in the State shall be punished by fine 
or imprisonment. Any person who establishes or keeps a private insane 
asylum without a license from the Governor or council, unless otherwise 
authorized by law, shall forfeit a sum not exceeding $500. 



MICHIGAN.^ 



When a person, indigent, but not a pauper, appears to be insane, 
application may be made to the judge of probate of the county where he 
resides. The judge shall appoint a time for a hearing, and notify the 
alleged insane person. He shall call two respectable physicians and 
other witnesses, and shall notify the prosecuting attorney of the county 
and the supervisor of the township or ward where the insane person 
resides, whose duty it shall be to attend. If the judge, after a full inves- 
tigation, either with or without the verdict of a jury, at his discretion, 
shall find him insane and also indigent, he shall make a certificate, and 
the patient shall be admitted into the asylum and supported there at the 
expense of his county until he is cured, if his cure is effected within two 
years, and until otherwise ordered. The judge of probate shall notify 
the supervisors of his county of the result of the proceedings, and they 
shall raise the money required for the patient's support. 

If a pauper becomes insane, the county superintendents of the poor, or 
any supervisor of any city or town Avhere the pauper belongs, shall make 
application to the probate judge of the county, who shall make an inves- 
tigation and shall call one or more respectable physicians and other 
witnesses, and, if satisfied of the person's insanity, sliall make a certifi- 
cate and have him sent to the insane asylum, as in the case of a person 
in indigent circumstances. No insane person, not a criminal, shall be 
confined in any jail more than ten days, nor for any time in the same 

1 Compiled Laws of Michigan, 1871, Yol. II. pp. 1482, 2167, 2168, 2178, 21%. 
Laws of Michigan, 1873, pp. 226, 227; 1877, p. 120. Howell's Annotated Statutes. 
Michigan, 1882, Vol. I. pp. 513-530. 



476 APPENDIX — MICHIGAN. 

room with a person charged with, or convicted of, crime. When an 
indigent insane person has been sent to the asylum by his friends who 
have paid his bills there for three months, if the superintendent certify 
that he is a fit patient, the supervisors of the county of his residence are 
required to defray the expenses of his remaining thereafter. Extra care 
and attendance may be allowed patients if specially contracted for. 

The town or county officers sending a patient to the asylum, shall pro- 
vide during the removal a female attendant to every female patient, unless 
accompanied by her husband, father, brother, or son. 

If a patient has no legal settlement in any county or township, the 
expense of his support in the asylum shall be paid by the State. 

The probate judge committing any indigent insane person or insane 
pauper shall inquire into and determine whether he has a legal settlement 
and where it is. 

The trustees of the difierent asylums shall meet jointly once or more 
each year, and may transfer patients from one hospital to another if it is 
necessary or desirable. 

So long as there is room for the insane in the wards of the State 
asylums, it shall be illegal to consign any insane person to the county 
almshouses. 

No patient shall be discharged without suitable clothing, and if not 
otherwise provided, the steward shall furnish it, and also money not 
exceeding $20. 

When a person shall have escaped indictment, or shall have been 
acquitted of a criminal charge or a misdemeanor on the ground of insanity, 
the court shall carefully inquire and ascertain whether his insanity in 
any degree continues, and, if it does, shall order him in safe custody and 
to be sent to the asylum. 

If any person in confinement under indictment, or sentence of impris- 
onment, or on any criminal process whatever, shall appear to be insane, 
the circuit court commissioner of the county where he is confined, or, if 
he be absent, the judge of the circuit court, shall upon the application of 
the prosecuting attorney institute an investigation and call two respectable 
physicians. If the insanity is proved, the commissioner or judge may 
order the safe custody and removal of such person to the asylum, there to 
remain until restored to sanity. If the patient recovers, he shall be sent 
back to prison to be proceeded against criminally, kept in confinement, or 
discharged, as the case may be. 

If a person imprisoned on civil process becomes insane, like proceed- 
ings shall be resorted to, but notice shall be given to the plaintifi" or his 
attorney, if in the State. 

An insane criminal may be discharged by order of one of the justices 
of the supreme court or a circuit judge when, upon due investigation, it 
appears safe, legal, and right, to make such order. 

All insane soldiers and marines of the State shall be removed to the 
insane hospitals, and there provided for at the expense of the State. 

If any convict shall show symptoms of insanity while serving sentence, 
the warden shall give notice to the physician of the prison and to the 
medical superintendent of the insane asylum at Kalamazoo. They shall 
forthwith examine such convict, and, if they find him insane, shall certify 



APPENDIX — MINNESOTA. 477 

the fact to the warden, who shall forthwith put the convict in the insane 
department of the prison, and notify the Governor of his condition. The 
Governor shall inquire into the facts, and may order the lunatic to be 
conveyed to one of the State asylums for the insane. If the convict 
recovers his sanity before his term of sentence has expired, he shall be 
returned to the prison to serve out the unexpired time. If the Governor 
does not order the removal of such convict to the insane asylum, the 
physician of the prison shall give him such treatment as circumstances 
will permit in the insane department of the prison. If the convict so 
treated recovers his sanity, or so far recovers that it is safe for him to 
work, the warden shall put him at hard labor according to his sentence. 

If a convict at the expiration of his term of sentence is deemed insane, 
and is so certified by the physician of the prison, and none of his friends 
or relatives appear to take charge of him, the warden or officer in charge 
shall give notice to the county clerk of the county from which the convict 
was sent, and to one or more relatives or friends of the prisoner, and also 
to the probate judge of the county where the prison is located. The 
probate judge shall order the sheriff of the county to receive the convict 
on his discharge and bring him before him. The judge shall then call 
two respectable physicians and other witnesses, and shall notify the prose- 
cuting attorney of his county, whose duty it shall be to appear and act 
in behalf of the State. The judge shall fully investigate the facts, 
either with or without a jury, and, if he finds the person insane and no 
relative or friend ready to take charge of him, he shall send him to one 
of the insane asylums of the State, to be kept until restored to sanity, or 
taken charge of by his friends or otherwise discharged. 

If such person is indigent and without relatives, liable for his support, 
he shall be supported in the asylum at the expense of the State. 

Whenever a person on trial for murder, or assault with intent to 
commit murder, or arson, pleads insanity, and is acquitted and found by 
the jury not guilty by reason of insanity, he shall be committed to the 
insane hospital connected with the State prison. Such person shall only 
be released on the certificate of the medical superintendent of the insane 
asylum at Kalamazoo, and the circuit judge of the court which committed 
him, stating that he has so far recovered as to be safe to go at large. On 
the filing of such a certificate with the Governor, he shall order the 
person to be discharged. 



MINNESOTA.^ 



Any insane person a resident of the State may be admitted to the 
hospitals and maintained at the public expense, free of charge to his or 
her relatives or friends, and all shall be treated as public patients. The 

1 Statutes of Minnesota, 1878, pp. 454-460, 598, 958. Laws of >[innosota, 1879, 
pp. 26, 38, 39. 



478 APPENDIX — MINNESOTA. 

probate judge, or, in his absence, the court commissioner of any county, 
upon information being filed before him that there is an insane person 
in his county needing care and treatment, shall cause the person alleged 
to be insane to be examined by a jury consisting of two respectable 
persons beside himself, one at least of whom shall be a physician, to 
ascertain the fact of insanity. If the person is found insane, a warrant 
shall issue directing that he be carried by the sheriff or some other suit- 
able person, and placed in the care of the superintendent of the insane 
hospital. It is the duty of the judge of probate, or court commissioner, 
with the assistance of the examining physician, to obtain, so far as 
possible, answers to certain prescribed questions relating to the history 
and condition of the patient, and to forward the same to the superinten- 
dent, when the patient is sent to the hospital. 

Patients shall be legally discharged by vote of the tmstees, and, for 
this purpose, three shall constitute a quorum. When a patient is dis- 
charged as cured, the superintendent shall furnish him with suitable 
clothing and money sufficient to pay his expenses home, unless otherwise 
supplied. 

The relatives of any person charged with insanity or found to be in- 
sane shall have a right to take charge of and keep said insane person if 
they shall desire to do so ; but the probate judge or court commissioner 
may require a bond of such relatives for the proper and safe keeping of 
such person. If the relatives or friends of any patient kept in the hos- 
pital shall ask for his discharge, the superintendent may require a bond 
conditioned for the safe keeping of such patient : Provided, that no 
patient under the charge of, or convicted of, homicide shall be discharged 
without the consent of the superintendent and board of trustees. When- 
ever a patient is discharged from either asylum, the superintendent shall 
send notice of the same to the judge of probate who issued the warrant 
for the commitment. 

The superintendent of each hospital is required, once a month, to 
make out a written report of the condition of each patient in the hospital, 
and to send a copy to the next of kin of each of said patients. 

A commission appointed by the Governor, consisting of three physi- 
cians, of whom one shall be a member of the State Board of Health, 
shall visit the hospitals for the insane once in every six months, or at the 
request of the Governor, to examine their sanitary and general condition, 
and to inquire into the condition of the patients, and make a report in 
detail to the Governor. This commission, if they find patients whose in- 
sanity they have reason to doubt, may remand them to the probate courts 
by which they were committed, to be there detained under proper surveil- 
lance until the judge is satisfied of their sanity or insanity. If any patient 
is thus found to be sane, he shall be discharged by the probate court ; other- 
wise he shall be recommitted to the hospital ; but no person charged with 
a crime shall be so discharged. Idiots and feeble-minded children may 
be removed by the commissioners and sent to the Asylum for the Deaf, 
Dumb, and Blind, to be there treated. 

When any person indicted for an ofience is on trial acquitted by reason 
of insanity, if the discharge or going at large of such person is considered 
by the court dangerous to the community, the court may order him to be 



APPENDIX — MISSISSIPPI. 479 

committed to the Hospital for the Insane for safe keeping and treatment, 
or may order him to be committed to prison, or may give him into the 
care of his friends, taking bonds that he be well and securely kept. 

Whenever a convict in the State Prison shall, in the opinion of the 
warden and board of inspectors thereof, be regarded as insane, it shall be 
the duty of said board to call in two skilled physicians, one of whom may 
be the prison physician, who shall, without employing cruel or inhuman 
tests, make a careful examination as to the insanity of such convict, and 
render a report, to be entered on the prison records. If the convict is 
found insane, the board shall notify the Governor, who shall have the 
prisoner sent to the insane hospital, there to be kept and treated. If 
such a patient is cured of the mental disability on account of which he 
was committed to the hospital, and his term of sentence has not expired, 
the Governor shall be notified, and the convict shall be remanded to the 
State Prison. 



MISSISSIPPI.^ 



Any person, being a lunatic and a resident of the State, may be ad- 
mitted into the asylum free of charge, the expenses of removal to be paid 
by the county from which the insane person was sent, or in which he had 
his settlement; but if the patient is able, he shall pay for the expense of 
his removal. The superintendent of the asylum, provided there is room, 
shall admit all persons ordered to be placed therein by the chancery 
court after an inquest of lunacy. 

When an application is made by the friends or relatives of a lunatic 
to the chancery court, if the court is satisfied there is probable cause, 
it shall order the sheriff to summon the person alleged to be of unsound 
mind, and six good men of the county in no way related to the party, to 
try the question of insanity. If the person is judged by the inquest, or 
a majority of them, to be incapable of taking care of himself, they shall 
certify the same to the court, and the court or chancellor, or clerk in 
vacation, shall appoint some suitable person guardian of such lunatic, 
directing the guardian to take care of the person and his estate. If the 
case requires it, the court or clerk may direct confinement in the lunatic 
asylum. 

In case the friends or relations of any lunatic shall neglect or refuse 
to place him in the asylum, and shall allow him to go at large, the clerk 
of the chancery court of any county in which such lunatic may reside 
or be found going at large, on the suggestion, in writing, of any citizen, 
shall direct the sheriff to summon the lunatic and six discreet persons 
to make inquisition. If the person is adjudged by the inquest, or a 

1 Revised Code of Mississippi, 1880, pp. 'J05-210, 581-588, 794, 795, 80i', 80o. 
Laws of Mississippi, 1882, pp. 61-65. 



480 APPENDIX — MISSOURI. 

majority of them, to be insane, and a fit subject for the asylum, the 
clerk shall order the sheriff to take the lunatic and place him in the 
asylum, if there be a vacancy, or, if there be no vacancy, to confine him 
in the county jail until room can be had in the asylum. 

If any patient is found incurable, but harmless, the superintendent 
shall have him removed to the county where he belongs, there to be cared 
for by his guardian or his friends, or, if he is poor and has no friends 
who are able, he shall be maintained as a poor person by the county. 

If the superintendent and trustees think that a lunatic w^ho is a resi- 
dent of the State ought to be admitted as a patient, they may receive 
him, even though no proceedings in lunacy have been instituted. The 
trustees may adopt such rules as they think proper in regard to requiring 
a statement of the case and a history of the patient, to be presented with 
the application for admission. 

When a person is charged with the commission of an offence, and it 
appears that he was insane when the offence was committed, and still is 
insane, he shall not be discharged, but the case shall be reported to the 
chancellor or clerk of the chancer}^ court of the proper county, whose 
duty it shall be to proceed with the case according to the law relating to 
persons non compos mentis. 

When the grand jury fails to indict, or a traverse jury fails to convict, 
a person by reason of his insanity, and it is found that the person is still 
insane and dangerous, notice shall be given to the proper chancellor or 
clerk of the chancery court, whose duty it shall be to proceed with such 
person and his estate according to the law relating to insane person. 

If the sheriff is satisfied that any convict under sentence of death is 
insane, he shall, with the concurrence of the judge of the circuit court, 
or the chancellor, or the president of the board of county supervisors, in 
the absence of such circuit judge, summon six physicians, if to be had, 
and, if not, six other discreet men, to inquire into such insanity. If the 
convict is found insane, the verdict shall be transmitted to the Governor, 
and the execution suspended until the Governor is satisfied that the 
convict has become sane. 



MISSOURI.^ 



Persons afilicted with any form of insanity may be admitted into an 
insane asylum when the superintendent thinks they will be benefited by 
the care and treatment of the institution ; and any patient may be dis- 
charged by the superintendent if longer treatment is not likely to improve 
his condition. The indigent insane of the State shall always have the 
preference over those who have the ability to pay, and, if there is not 

1 Eevised Statutes of Missouri, 1879, Vol. I. p. 325 ; Vol. II. pp. 818-828, 1133, 1138. 
Laws of Missouri, 1881, pp. 123, 141 ; 1883, pp. 78, 79. 



APPENDIX — MISSOURI. 481 

room in the asylum for all the insane persons in the State, recent cases 
(of less than a year's standing) shall have the preference; but no county 
shall have in the institution more than its just proportion, according to 
its insane population. There shall be sent with each patient a detailed 
account of his case, as far as practicable, stating the cause of his insanity, 
its duration, the former treatment of the patient, and all other particu- 
lars; and, if possible, some one acquainted with the individual should 
accompany him to the asylum, from whom minute particulars of his in- 
sanity may be learned. 

Pay patients, those not sent by order of the court, are admitted as 
follows : The superintendent shall be furnished with a request in a pre- 
scribed form, and with a certificate, dated within two months, in pre- 
scribed form, signed by two physicians, stating the patient to be insane. 
Thirty days' charges must be paid in advance, and a sufficient bond 
given in prescribed form to secure future expenses, and the removal of 
the patient when desired. 

County patients are admitted as follows: The several county courts 
shall have power to send to the asylum such of their insane poor as may 
be entitled to admission. The counties thus sending, shall pay semi- 
annually, in cash, in advance, for the support of their insane poor, the 
*price of board to be fixed by the board of managers. Some citizen in 
the proper county must file with the clerk of the county court a state- 
ment, in prescribed form, that the person is insane and a recent case, 
and has no property. It shall give the names of two witnesses who can 
swear to the facts, one of whom shall be a respectable physician. The 
clerk shall thereupon summon the witnesses named to appear at a speci- 
fied time, also such other persons as he thinks proper. At the time 
appointed, unless there is an adjournment, there shall be a trial before 
the court, either with or without a jury. 

If the facts stated shall be found true, an order shall be entered of 
record, stating that the person found to be insane is a fit subject for 
treatment in the asylum. The order shall require the medical w^itness to 
make out a detailed history of the case, and also that the clerk of the 
court make application to the superintendent of the asylum for the 
patient's admission. If the patient is dangerous to be at large, that fact 
shall be set forth. The superintendent, on receiving the application and 
a copy of the order of the court, shall immediately advise the clerk 
whether the patient can be received, and, if so, at what time. If the 
patient can be admitted, the clerk shall issue his warrant to the sheriif 
or some suitable person, the relatives of the insane person having a pref- 
erence, directing that the insane person be arrested and conveyed to the 
State Lunatic Asylum. If there is necessity, he may authorize one or 
more assistants. The superintendent shall acknowledge on the writ the 
receipt of the patient, and the warrant shall be returned into court. 

A pay patient may become a county patient, if the county court so 
order. In such case, the clerk of the court shall send to the superinten- 
dent a certificate, stating that the patient has not estate sufficient to 
support him in the asylum. A county patient may become a ptiy patient 
by order of the county court, and tlie filing of the proper certificate, 
stating the ability of the patient to pay. 

31 * 



482 APPENDIX — MISSOURI. 

Whenever the superintendent desires the removal of a county patient 
from the asylum, he shall notifv the clerk of the county court of the 
county from which such patient was sent, and the clerk shall have the 
patient removed by the sheriif. 

If any person, by lunacy or otherwise, shall be furiously mad or 
dangerous, it shall be the duty of his guardian, or other person under 
Avhose care he may be, to confine him in some suitable place until the 
next sitting of the probate court for the county, when such order shall be 
made by the court for the restraint, support, and safe keeping of the 
person, as the cux-umstances of the case shall require. 

If the persons in charge of such an insane patient fail to confine him, 
or if there is no one in charge of him, any judge of a court of record, 
or any two justices of the peace, may cause him to be apprehended, and 
may employ some one to confine him in a suitable place until the probate 
court makes such further orders as the case may require. 

When a person tried upon indictment for any crime or misdemeanor 
shall be acquitted on the sole ground that he was insane when the offence 
was committed, the fact shall be found by the jury in their verdict, and 
also whether the prisoner has recovered or not. If the prisoner has 
recovered, he shall be discharged. If he has not recovered, and is not a 
poor person, and the court is satisfied it would be unsafe to permit him 
to go at large, the court shall order that he be sent to the asylum. The 
sheriff shall keep such prisoner in the county jail, poor-house, or other 
safe custody, until such time as he can be received into the asylum, and 
then shall transfer him there. The costs and the expense of maintaining 
such insane person shall be taxed by the court each term, and collected 
out of the prisoner's estate. If the prisoner is a poor person, the court 
shall order him to be kept in safe custody by the sheriff until the county 
court shall cause him to be removed to the asylum, as in the case of 
insane poor persons ; provided, however, that no farther examination 
into the insanity of the prisoner need be made. By an indigent or poor 
insane person is meant one who is worth, above his debts, and excluding 
property exempt fr'om execution, less than 8300 : or, if he has a family, 
less than 81000, after deducting out also the expense of supporting his 
family for one year. 

If any convict, before the execution in whole or in part of the sentence 
of the court, becomes insane, it shall be the duty of the Governor to 
inquire into the facts ; and he may pardon such lunatic, or commute the 
execution, and may order such lunatic to be conveyed to the asylum, and 
there kept until restored to reason. If the sentence is only suspended 
for a time, it shall be executed at the expiration of the period, unless the 
Governor direct otherwise. If any person, after indictment and before 
trial, becomes insane, the circuit or criminal court wherein such person 
stands charged shall suspend proceedings, and order a jury to be sum- 
moned to try the C|uestion of the insanity of the person. The judge shall 
notifv the prosecuting attorney of the inquiry, and also the alleged insane 
person, unless the court order him to be brought before it. If the juiy 
find that the person has become insane, the judge shall order him to be 
sent to the lunatic asylum. If he ever recovers his sanity, the proceed- 
ings against him shall go on as if there had been no interruption. If the 



APPENDIX— MONTANA. 483 

jury find that he has not become insane, then the trial shall go on in the 
same manner as though no such inquiry had been made. 

If, after any convict is sentenced to the punishment of death, the 
sheriff has cause to believe that he has become insane, he may summon a 
jury of twelve men, and give notice to the prosecuting attorney, and have 
the question tried. If it is found that such convict is insane, the sheriff 
shall suspend the execution until he receives a warrant from the Grovernor 
or the court, directing him to proceed with the execution. 



MONTANA,^ (Territoey.) 

There being as yet no public insane asylum established, the commis- 
sioners of the insane are authorized to make a contract with some person 
to take charge of and care for insane persons who shall be delivered to 
him. The Governor also may make contracts for the care of the indigent 
insane of the Territory, and may pay the expense of sending patients out 
of the Territory to their friends if he deem it advisable. 

It is the duty of the probate judge, or, in his absence or inability 
to act, of the chairman of the board of county commissioners of the 
several counties (upon the application of any person, under oath, stating 
that any person, by reason of insanity, is unsafe to be at large, or is suf- 
fering from mental derangement), to cause such person to be brought 
before him, and also a jury of three citizens of his county, one of whom 
shall be a licensed practising physician. A hearing shall be had by the 
jury, and an examination shall be made of the alleged insane person. If 
the jury, after a careful examination, certify that the charge is correct, 
and the probate judge or commissioner is satisfied that such person, by 
reason of insanity, is unfit to be at large, or is incompetent to provide for 
his own proper care and support, and has no property, and no near 
kindred of sufiicient means to provide for such maintenance, or if such 
kindred neglect and refuse to care for him, then the judge or county 
commissioners shall make out duplicate warrants, reciting the facts, and 
give them to the sheriff", who shall immediately convey the insane person 
named and deliver him to the contractor employed to care for insane 
persons. The contractor shall acknowledge the receipt of the patient, 
and the warrants shall be returned, one to the judge or county commis- 
sioner issuing it, and the other to the secretary of the board of commis- 
sioners of the insane. 

When it is represented to the probate judge, upon verified petition of 
any relative or friend, that any person is insane or mentally ineoiupetcnt 
to manage his property, the judge must cause a notice to be given to the 

^ Laws of Montana, Kcvised Statutes, 1879, pp. 259, 260, 387, 388, 3-18, 448, 449, 
555-559. Laws of Montana, 1883, pp. 112, 113. 



484 APPENDIX — MONTANA. 

supposed incompetent person five days, at least, before the hearing, and 
such person, if able to attend, must be produced before him. If, after a 
fiill hearing and examination, it appear to the probate judge that the 
person in question is incapable of taking care of himself, he shall appoint 
a guardian, who shall have the care and custody of the person of his 
ward and the management of his estate. The question of the patient's 
restoration to sanity may be determined by petition to the probate judge, 
who shall summon a jury and have the question tried. 

All persons adjudged insane, whether indigent or not, shall be cared 
for by the Territory, if so desired, under the contract made by the Gov- 
ernor of the Territory for the care and maintenance of indigent insane ; 
and no person so adjudged insane shall be refused admission into any 
asylum provided by the Territory, nor shall the Territory ask or receive 
any compensation therefor. 

If any defendant in a criminal case, upon whom the court is about to 
pass judgment, declare that he is insane, the court, if it finds there is 
reasonable cause for believing the declaration, may order a jury to be 
impanelled, and a trial had. If the jury find that the defendant is 
insane, the court shall order him to be placed in the custody of the person 
provided by law for the keeping of insane persons ; if no such person is 
provided, then to the custody of some suitable person. Whenever it shall 
appear to the satisfaction of the court that such person has become sane, 
it shall order him to be produced for judgment. 

If any defendant, at the time he is arraigned, declares that he is in- 
sane, or there is reasonable cause for believing him insane, the like 
proceedings shall be had as in the case of a prisoner about to receive 
judgment. If the jury find that the defendant is sane, the trial shall 
proceed ; but if insane, the defendant shall be delivered to the custody of 
the person provided by law for the keeping of the insane, or to the 
custody of some suitable person. If the defendant recover his sanity, 
the trial shall proceed. 

If, after any criminal is sentenced to death, the sherifi" has cause to 
believe that such criminal has become insane, he may summon a jury of 
twelve competent jurors, with the concurrence of the judge of the court 
by which the judgment was rendered, to inquire into such insanity, 
giving notice thereof to the prosecuting attorney. If it is found by the 
jury that such criminal is insane, the sheriff shall suspend the execution 
of the sentence until he receives a warrant from the Grovernor, or from 
the supreme or district court, directing the execution of the criminal. 
The Governor, as soon as he is convinced that the criminal has recovered 
his sanity, may appoint a time for the execution, or may, in his discre- 
tion, commute the punishment to imprisonment for life. 

Whenever it appears that a territorial convict is insane, the warden, or 
other officer in charge of the penitentiary or prison, shall certify the fact 
to the probate judge of the county in which the prison or penitentiary 
is. The judge shall cause the convict to be brought before him, and at 
the same time and place a jury of three citizens of his county, one of 
whom shall be a licensed physician. If the jury, after a careful exami- 
nation, certify that the charge is correct, the judge shall have such insane 
person delivered over to the contractor for the custody, maintenance, and 



APPENDIX — NEBRASKA. 485 

treatment of insane persons. If, before the expiration of said convict's 
sentence, it appears to the contractor that he is restored to reason, he 
shall notify the sheriff, and such convict shall be confined in the prison 
or penitentiary for the remainder of his term. 



NEBRASKA.^ 



In each organized county there shall be a board of commissioners of 
insanity of three members, who may subpoena witnesses, administer oaths, 
etc. The clerk of the district court shall be ex officio clerk of the board. 
The other two members shall be appointed by the judge of the district 
court, and one of them shall be a respectable practising physician, and 
the other a respectable practising lawyer. In case of the temporary 
absence or inability to act of two of the commissioners, the judge of the 
district court may act in the place of one of the commissioners, or the 
commissioner present may call to his aid a respectable practising physi- 
cian or lawyer. The commissioners shall have cognizance of all applica- 
tions for admission to the hospital, or for the safe keeping otherwise of 
insane persons in their respective counties, except in cases specially pro- 
vided for. 

Applications for commitment shall be made in the nature of an infor- 
mation alleging that the person is believed by the informant to be insane 
and a fit subject for treatment in the hospital, and must state that such 
person is found in the county, and give what is known in regard to his 
settlement. The commissioners shall at once investigate the case, and 
may require the alleged insane person to be brought before them, and 
kept in suitable custody until their investigation is concluded ; but they 
may dispense with this, if they think it will be injurious to such person, 
or for any reason deem it unnecessary. They shall hear the testimony 
ofi'ered for and against the application, and in each case shall appoint 
some regular practising physician of the county, who may, or may not, 
be of their own number, to see the alleged insane person, and make a 
personal examination. This physician shall make a certificate, stating 
whether or not he finds the person insane, and, in connection with his 
examination, he shall endeavor to obtain from the relatives of the insane 
person, or from others, correct answers to certain prescribed questions 
touching the history and condition of the patient. The questions and 
answers shall be attached to his certificate. On the return of this certi- 
ficate, the commissioners shall find whether the person alleged to be 
insane is insane, and whether he is a fit subject for treatment in the 
hospital. They shall also state what is ascertained about his settlement. 
If the person is found insane, they shall issue a warrant authorizing the 

^ Compiled Statutes of Nebraska, Guy A. Brown, 1881, pp. *J02, oOcUaOi), To'J, 747. 



486 APPENDIX — NEBRASKA. 

superintendent of the hospital to receive and keep such person as a 
patient. The sheriff shall then deliver the patient, with the physician's 
certificate and the order of the court, to the superintendent of the hos- 
pital. If the sheriff is not at hand, the commissioners may appoint some 
other suitable person to execute the warrant : but no female shall be taken 
to the hospital without the attendance of some other female or some rela- 
tive. Any relative or friend of the patient, who is a suitable person, 
shall have the privilege, if he so request, of executing the warrant, but 
shall receive no fees for so doing. The warrant endorsed by the super- 
intendent, acknowledging the receipt of the patient, shall be returned to 
the clerk of the commissioners. 

If a patient has a legal settlement in any county, his expenses shall be 
paid by that county. If he has no legal settlement, his expenses shall 
be paid by the State. All patients shall be on an equal footing in the 
hospital, except that if the relatives or immediate friends of any patient 
shall desire it, and shall pay the expense thereof, a patient may have 
special care. The relatives or friends of any patient in the hospital shall 
have the privilege of paying any portion, or the whole, of the expenses 
of such patient. 

If the hospital is fall, or if for any reason the patient cannot be 
received and it is not safe that he be allowed to 2:0 at libertv, the com- 
missioners shall require that such patient be suitably provided for 
otherwise, until such admission can be had. Such patients shall be cared 
for either as public or as private patients. Those shall be treated as 
private patients whose relations or friends will agree to provide for them 
without public charge. The commissioners shall appoint some suitable 
person as special custodian to restrain and care for such patients in such 
way as best to secure their comfort and safety and the safety of others. 

In the case of public patients, the commissioners shall require that they 
be restrained and cared for by the commissioners of the county or over- 
seers of the poor at the expense of the county. If there is no poor-house 
for the reception of such patients, or if no more suitable place can be found, 
they may be confined in the jail of the county in charge of the sheriff. 

Where persons are alleged to be insane, but it is not desired to send 
them to the hospital, the commissioners of the insane, on application, 
may make examination, and, on proof of their insanity and need of 
care, may make provision for their restraint and care within the county, 
either as public or private patients. 

Insane persons who have been under care outside of the hospital by 
authority of the commissioners of the insane of any county may, on 
application, be transferred by the commissioners to the hospital, when- 
ever they can be admitted thereto. If the admission is within six months 
after the inquest already had, another inquest shall not be necessary, 
unless the commissioners deem it advisable. 

If it becomes necessaiy. for want of room in the hospital, to discrimi- 
nate in the general reception of patients, a selection shall be made as fol- 
lows : (1) Recent cases (of less than one year's duration). (2) Chronic 
cases (of more than a year's standing, but with favorable prospects of 
recovery). (3) Cases which have been longest on file. (4) The indigent 
have a preference, other things being equal. 



APPENDIX — NEBRASKA. 487 

Any patient who is cured shall be immediately discharged by the 
superintendent. Upon such discharge, the patient, if not otherwise 
supplied, shall be provided by the superintendent with suitable clothing 
and a sum of money not exceeding $20. 

If a patient proves incurable and is not dangerous to be at large, his 
relatives, with the consent of the board of trustees, may remove and take 
charge of him. 

If a patient in the hospital is not cured and is dangerous to be at large, 
the commissioners of insanity of the county where he belongs, on making 
provision for the care of such patient within the county, may authorize 
his discharge, if the relatives or immediate friends request it. 

The board of trustees, or, in the interim between the meetings of the 
board, the superintendent with two trustees, may order the discharge or 
removal of incurable and harmless patients, whenever it is necessary to 
make room for recent cases. If patients so discharged need further care, 
the commissioners of insanity shall be notified, and shall at once provide 
for their care in the county. 

If it is alleged that a person confined as a patient in the hospital is not 
insane, and is unlawfully detained, a judge of the district court of the 
county in which the hospital is situated, or of the county where the 
person detained belongs, shall appoint a commission of not more than 
three persons, one of them a physician, and, if two or more are appointed, 
one a lawyer, and they shall inquire into the merits of the case. They 
shall have an interview with the patient in such manner as they deem 
most desirable, shall talk with the ofiicers, and examine the records of the 
hospital. They shall then make a report to the judge, and shall accompany 
their report with a statement of the case signed by the superintendent. 
If the judge shall find the person not insane, he shall order his discharge. 
Such a commission shall not be repeated ottener than once in six months, 
in the case of any one patient, nor shall it be appointed within six 
months of the patient's commitment. 

The provisions in regard to the support of the insane at public charge 
are not construed to release the estates of such insane persons, nor their 
relatives, from liability for their support, but the board of county commis- 
sioners may release the relatives from a portion, or even the whole of the 
burden, if they think it reasonable and just to do so. 

No idiots shall be received or kept in the hospital, and any such there 
shall be sent to the counties where they belong. 

If it is shown to the satisfaction of the commissioners of insanity of 
any county that a person kept as a patient within the county is no longer 
in need of care, they shall at once order his discharge. 

Insane persons from other States and Territories may be received on 
the same footing, and on the same conditions as private pay patients. 

A person who becomes lunatic or insane after the commission of a crime 
or misdemeanor, ought not to be tried for the offence during the continuance 
of the lunacy or insanity. If, after verdict of guilty and before judg- 
ment pronounced, such person become lunatic or insane, no judgment 
shall be given while such lunacy or insanity shall continue. If, after 
judgment and before execution of the sentence, such person shall become 
lunatic or insane, then, in case the punishment be capital, the execution 



488 APPENDIX — NEVADA. 

thereof shall be stayed until the recovery of said person. In all such 
cases it shall be the duty of the court to impanel a jury to try the ques- 
tion whether the accused be, at the time of impanelling, insane or not. 

In the case of convicts, sentenced to death, who appear to be insane, a 
judge of the district court shall summon a jury of twelve men to inquire 
into such insanity, and shall give notice of the time of trial to the district 
attorney. If the finding shall be that the convict is insane, the judge 
shall suspend the execution, and notice shall be sent to the Governor. 
When the Governor becomes satisfied that the convict has recovered his 
sanity, he may appoint a time for the execution. 

No person alleged to be insane shall be restrained of his liberty, other- 
wise than as provided by law, except for the safety of persons or property 
until the proper authority can be obtained ; and any one abusing or 
treating an insane person with wanton cruelty or severity, shall be guilty 
of a misdemeanor, and liable to an action for damages. 



NEVADA.! 



The judge of the district court in each judicial district, upon the 
application of any person under oath, setting forth that any person, by 
reason of insanity, is unsafe to be at large, or is suffering under mental 
derangement, shall cause the said person to be brought before him at a 
time appointed, and shall also cause to appear, at the same time, one or 
more licensed practising physicians, who shall examine the person alleged 
to be insane. If the physician, after a careful examination, shall certify 
upon oath that the charge is correct, and if the judge is satisfied that the 
person, by reason of his insanity, is unfit to be at large, and is incom- 
petent to provide for his own care and support, and has no property 
applicable to the purpose, and has no near kindred within the State of 
sufficient means or ability to care properly for him and his support, he 
shall cause such indigent insane person to be conveyed to the insane 
asylum of the State, and placed in charge of the superintendent. 

Paying patients, whose friends or property can pay their expenses, 
shall pay according to the terms directed by the board of commissioners ; 
but the insane poor shall in all respects receive the same medical care and 
treatment from the institution, and no record of debt shall be made against 
them. 

When an indictment is called for trial, or, upon conviction, the defen- 
dant is brought up for judgment, if a doubt shall arise as to his sanity, 
the court shall order the question to be submitted either to the regular 
jury, or to a jury specially called to inquire into the fact. The trial of 

1 Compiled Laws of Nevada, 1873, Vol. I. pp. 206, 525, 526, 539, 540; Vol. II. 
pp. 388, 384. Statutes of Nevada, 1879. p. 140; 1881, pp. 59-63; 1883, pp. 102, 103. 



APPENDIX — NEW HAMPSHIRE. 489 

the indictment shall be suspended until the question of sanity is deter- 
mined. 

The mode of proceedings at the trial is prescribed. If the jury find 
that the defendant is sane, the trial of the indictment shall proceed, or 
judgment be pronounced, as the case may be. If he is found insane, the 
trial or judgment shall be suspended until he becomes sane, and the 
court, if it deem the prisoner's discharge dangerous to the public, may 
order that he be committed to the care and custody of some proper per- 
son, and that upon his becoming sane he be redelivered to the sheriff, 
who shall place him in proper custody until he be brought to trial or 
judgment, as the case may be, or be legally discharged. 

If, after the judgment of death, there be good reason to suppose that 
the defendant has become insane, the sheriff, with the concurrence of the 
judge who rendered judgment, may summon a jury of twelve men to 
inquire into the supposed insanity. The district attorney shall attend 
the inquisition. If it be found that the defendant is insane, the sheriff 
shall suspend the execution of the judgment until he receives a warrant 
from the Governor, who, when the defendant recovers his sanity, may fix 
a day for the execution. 

Whenever a convict, while undergoing imprisonment in the Nevada 
State Prison, shall become insane, and be so adjudged by a commission 
of lunacy appointed by the court, as in other cases of insanity, it shall 
be the duty of the warden to deliver such convict to the superintendent 
of the State Insane Asylum for detention and treatment. 

If such convict be restored to sanity before the expiration of his sen- 
tence, the superintendent shall deliver him to the warden of the prison, 
to be retained therein for the unexpired term of his sentence, unless said 
convict shall be released by order of the board of pardons. 



xXEW HAMPSHIRE.^ 

If any insane person is in such condition as to render it dangerous 
that he should be at large, the judge of probate, upon petition of any 
person, and such notice to the selectmen of the town in which such insane 
person is, or to his guardian, or to any other person as he may order — 
all which may be done as well in vacation as in term time — may commit 
such insane person to the asylum. 

Any insane pauper supported by any town may be committed to the 
asylum by order of the overseers of the poor, and there supported at the 
expense of the person, town, or county chargeable with his support. If 
the overseers neglect to make such order in relation to any insane county 
pauper, the supreme court, or any two judges thereof in vacation, may 

^ General Laws of New Hampshire, 1878, pp. 00-G3, 595-597. New llauipsliire 
Laws, 1879, p. 389 ; 1881, p. 530. 



490 APPENDIX — NETT HAMPSHIRE. 

order such pauper to be committed to the asylum and there supported at 
the expense of the county. 

The parent, guardian, or friends of any insane person may cause him 
to be committed to the asylum, with the consent of the trustees, and there 
supported on such terms as they may agree upon. No person shall be 
committed to the Asylum for the Insane, except by the order of the court 
or the judge of probate, without the certificate of two reputable physicians 
that such person is insane, given after a personal examination within a 
week of the committal ; and such certificate shall be accompanied by a 
certificate from the judge of the supreme court, or court of probate, or 
mayor, or chairman of the selectmen, testifying to the genuineness of the 
signatures and the respectability of the signers. 

Any insane person committed to the asylum by his parent, guardian, 
or friends, who has no means of support, and no relatives of sufficient 
ability chargeable therewith, and no settlement in any town, and who is 
unsafe to be at large, shall be supported by the county from which he 
was committed. 

If any insane person is confined in any jail, the supreme court may 
order him to be committed to the asylum, if they think it expedient. 

Any insane person committed to the asylum by order of the supreme 
court, such person having been charged with an offence the punishment 
whereof, as prescribed by law, is death or confinement in the State Prison, 
shall be supported at the expense of the State. 

Any person committed to the asylum may be discharged by any three 
of the trustees, or by any justice of the supreme court, whenever the 
cause of commitment ceases, or a further residence at the asylum is not 
necessary. 

But any person so discharged, who was under sentence of imprison- 
ment, which has not expired, shall be remanded to prison. 

Some of the trustees shall visit the asylum at least twice a month, and 
shall give the patients an opportunity to see them in private. If, in their 
opinion, a further residence at the asylum is not necessary for any patient, 
it shall be their duty to discharge him. Patients are to be furnished with 
writing materials, and may send letters to the board of trustees, which 
shall be delivered without inspection. 

Whenever the grand jury shall omit to find an indictment against any 
person for the reason of insanity or mental derangement, or any person 
prosecuted for an offence shall be acquitted by the petit jury for the same 
reason, the court, if they are of opinion that it will be dangerous to the 
people that such person should go at large, may commit him to the 
prison, or to the Asylum for the Insane, there to remain until he is dis- 
charged by due course of law. 

The Governor and Council, or the supreme court, may discharge any 
such person from prison or transfer any prisoner to the Asylum for the 
Insane, whenever they are satisfied that such discharge or transfer will 
be conducive to the health and comfort of such person, and to the welfare 
of the public. 

In case of the sudden death of any patient in the asylum, a coroner's 
inquest shall be held. 



APPENDIX — NEW JERSEY. 491 



NEW JERSEYJ 



No person shall be committed to an insane asylum, except upon an 
order of some court or judge authorized to send patients, without lodging 
with the superintendent (1) a request, signed by the applicant, giving 
the name, residence, and various other facts regarding the patient, and 
(2) a certificate, dated within one month, signed by a respectable physi- 
cian, certifying the patient's insanity. Each person signing the request 
or certificate must give his residence and occupation. 

Each county shall be entitled to send its just proportion of patients. 
Whenever any pauper in a county entitled to send patients to the asylum 
may be insane, it shall be the duty of the overseers of the poor in the 
township where he resides to apply to a judge of the court of common 
pleas of the county. The judge shall call one respectable physician, and 
make an investigation, and, if satisfied that the disease is of such a nature 
as may be cured, he shall make a provisional order that the pauper be 
taken to the asylum, and kept until restored, if this be-effected in three 
years. Before this order shall take effect, it shall be submitted, with the 
other papers in the case, to the "chosen freeholders" of the township 
where such lunatic is found, who, if they are satisfied that the lunatic has 
a legal settlement in their county, shall endorse their approval upon the 
order, and it shall then be executed, and the pauper taken to the asylum. 
Copies of all the papers and proceedings shall be sent to the superinten- 
dent of the asylum. The case shall also be reported to the board of 
chosen freeholders, who shall raise the money for the pauper's support in 
the asylum. 

When a person who is in indigent circumstances, but not a pauper, 
becomes insane, application may be made to any judge of the court of 
common pleas of the county where he resides, and the judge shall call a 
respectable physician and other witnesses, and, either with or without the 
verdict of a jury, in his discretion, shall decide the case as to the patient's 
insanity and indigence. 

If he find the person insane, and his estate insufficient, he may make 
a certificate which will entitle the patient to admission to the asylum, and 
to support there, at the expense of tlie county, until he is restored to 
sanity, if effected in three years. If the investigation is made without 
summoning a jury, the certificate of the judge must be approved by the 
"freeholders" of the township in the manner above stated in the case of 
an insane pauper. 

When the expenses of an indigent patient in the asylum have been 
paid by his friends for six months, if the superintendent shall certify that 
he is a fit patient, and likely to be benefited by remaining in the institu- 
tion, the "chosen freeholders" of the count}^ of his residence, on appli- 
cation made, may defray the expenses of his remaining a year, and nu\y 

1 Revision of the Laws of New Jersey, 1709-1877, Vol. I. pp. 601-028; Vol. II. 
p. 1119. Laws of New Jersey, 1879, p.*176; 1880, pp. 89, 90, 1^04; 1888, p. lHik 



492 APPENDIX — NEW JERSEY. 

repeat the same for two succeeding years, upon like application, and the 
production of a new certificate from the superintendent each year. No 
patient is to be admitted for a less period than six months, except in 
special cases. 

When there are vacancies in the asylum, the managers may authorize 
the superintendent to receive paying patients upon the certificate of in- 
sanity by a regular physician, sworn to before a magistrate and by 
request of a responsible person, who shall give bonds. 

Town and county officers, sending a patient to the asylum, shall see 
that he is provided with suitable clothing. Money paid for the support 
of an insane person may be collected from his estate or from the persons 
liable to maintain him. 

The provisions above stated are not to abridge the power of the court 
of chancery over the person and property of insane persons. 

If the judge to whom application is made on behalf of an insane pauper 
is satisfied by the examination that such pauper, though not curable, can 
not be provided for by the overseers of the poor of the township, or at 
the poor-house of the township or county, with comfort, and without 
danger to himself and others, he shall order the pauper to be removed to 
the asylum. 

If the board of chosen freeholders of any county desire and request 
that a patient be kept in the hospital beyond the period of three years, 
it may be done, the county continuing to pay the expenses. 

Any patients, except those under a criminal charge, or liable to be 
removed to prison, may be discharged by the board of managers upon 
the superintendent's certificate of a complete recovery ; and they may 
send back to the poor-house of the county or township whence he came 
any person admitted as "dangerous" wdio has been two years in the 
asylum, upon the superintendent's certificate that he is harmless, and will 
probably continue so, and is not likely to be improved by further treat- 
ment. When the asylum is full, the managers may order the removal of 
a patient upon the superintendent's certificate that he is manifestly incur- 
able, and can probably be rendered comfortable at the poor-house ; and 
they may also discharge and deliver any patient, except one under a 
criminal charge, to his relatives or friends, who will undertake with good 
sureties for his peaceable behavior, custody, and maintenance, without 
further public charge. 

No patient shall be discharged without suitable clothing, and money 
not exceeding 810. 

If a person is lunatic, and in need of a guardian, a commission of 
lunacy shall issue out of the court of chancery, and an inquest shall be 
held. If the lunacy is found, the chancellor shall transmit a copy of all 
the proceedings to the orphans' court, where a suitable person shall be 
appointed as guardian, who shall have the care and safe keeping of the 
lunatic and his property. No lunatic or idiot shall be arrested or held 
in custody on any civil process, and if such a person is arrested, a writ 
of habeas corpus may issue. 

If any lunatic furiously mad or dangerous is found going at large, any 
two justices of the peace of the county where he is found may direct the 
overseers of the poor of the city or township to cause him to be appre- 



APPENDIX NEW JERSEY. 493 

hended, and safely locked up and chained, if necessary, in some secure 
place in the city or township where he has, or had, his last legal settle- 
ment. If he has no settlement that can be ascertained, he may be 
conveyed to any place provided in the county for the reception of maniac 
or lunatic persons, and, if there is no such place, he may be taken to the 
jail, there to be safely kept until his place of settlement is ascertained, 
or, failing in that, some order on the subject is made by the court of 
common pleas. 

The expenses shall be collected out of the estate of the lunatic, or, if 
he has no estate, they shall be paid by the township or county, according 
as he has a settlement or not. 

These provisions are not intended to abridge the authority of the chan- 
cellor touching such lunatic, nor to prevent any of the friends or relations 
of such person taking him under their own protection, so long as they 
can take care of him. 

• It is the duty of the overseers of the poor of the several townships in 
each county to make out a list of all the poor lunatics and idiots within 
their limits, giving all the facts connected with each case. If the board 
of chosen freeholders of the county think there is reasonable ground for 
believing that any of such persons can be restored to their right mind, 
they shall have them taken to the State Lunatic Asylum. 

When a person shall have escaped indictment, or have been acquitted 
of a criminal charge or of a misdemeanor upon trial, on the ground of 
insanity, the court shall carefully inquire w^hether his insanity in any 
degree continues, and, if it does, shall order him in safe custody, and to 
be sent to the asylum. 

If any person in confinement under indictment, or under any other 
than civil process, shall appear to be insane, the judge of the circuit court 
of the county where he is confined shall make an investigation, call a 
respectable physician and other witnesses, invite the prosecutor of the 
pleas to aid in the examination, and, if he deem it necessary, call a jury. 
If it is proved that the person is insane, the judge may discharge him 
from imprisonment, and order his safe custody and removal to the asylum, 
where he shall remain until restored to his right mind. Whenever he 
recovers, he shall be remanded to prison for further criminal proceedings, 
or be discharged. 

A criminal lunatic may be discharged by order of one of the justices 
of the supreme court if, upon due investigation, it shall appear safe, legal, 
and right to make such order. 

If any person confined in the State Prison as a convict shall appear 
to be insane, the judge of the circuit court of the county in which the 
prisoner is situated, shall, upon information of the foct from the physi- 
cian of the prison, institute an inquiry, call two respectable physicians 
and other witnesses, invite the Attorney-General to aid in the examina- 
tion, and, if he think it necessary, call a jury. If it is proved that the 
prisoner is insane, the judge may order his safe custody and removal to 
the State Lunatic Asylum, to remain at tlie expense of the State until 
restored to his right mind ; and then, if his term of imprisonment shall 
not have expired, he shall be remanded to the prison, to serve out the 
unexpired portion of his term of imprisonment. 



494 APPENDIX — NEW MEXICO. 

Insane persons may be sent to county asylums existing or to be estab- 
lished, instead of the State Asylum, when it is thought best. 

The board of managers are required to keep notes of their visits in a 
bound book kept for the purpose, to be inserted in their annual report to 
the Governor. 



NEW MEXICO.! (Territory.) 

If any person is alleged to be a lunatic or habitual drunkard, it shall 
be lawful for any district judge in the county where the person is or 
resides, to issue a commission to inquire into the lunacy or habitual 
drunkenness. No such commission shall issue except upon a petition in 
writing of a relation by blood or marriage of the person therein named, 
or of a person interested in the estate. The commission may issue to one 
person only, or to two or more. The judge shall make an order that 
notice be given to the alleged lunatic or habitual drunkard, or to some of 
his near relatives or friends. The commissioner or commissioners may 
direct the sheriff to summon six or twelve persons upon the inquest, as the 
case may seem to require. If the alleged lunatic or habitual drunkard is 
without property, to pay expenses, the judge in person may hold said 
commission during the term of the court, and have an inquest impanelled 
from the jurors attending the court. 

Every person aggrieved by any inquisition may traverse the same upon, 
or after, its return, and proceed to trial thereon before a jury. Notwith- 
standing any traverse that may be pending, the court may make such 
order as seems necessary for the care and custody of the person and the 
management of his estate. 

If the person is found a lunatic or habitual drunkard, it shall be 
lawful for the court to commit the custody and care of the person or 
estate, or both, of such lunatic to such person or persons as they shall 
deem most suitable. This committee shall give security, and shall have 
the management and control of the person and estate of the lunatic. A 
committee of the person may be appointed separately from the committee 
of the estate. 

No person found by inquisition to be a lunatic or habitual drunkard, 
shall be arrested on civil process ; and, if arrested, he shall be discharged 
by the court. 

If in any civil action any person arrested shall appear to be of unsound 
mind, the jailer or keeper shall give notice of the fact to two justices of 
the peace, who shall, within five days, attend at the prison and make an 
examination, and, if they find the person to be a lunatic, shall certify the 
same to the clerk of the district court. The court, or a judge thereof in 

1 General Laws of New Mexico, L. B. Prince, 1880, pp. 380-389. 



APPENDIX — NEW YORK. 495 

vacation, shall appoint a day for a hearing, and publish notice, and 
inform the creditor a week at least before the hearing, that application 
has been made for the discharge of the prisoner. If the court or judge, 
on the hearing, find the prisoner of unsound mind, an order shall be 
made for his discharge, provided that, if it appears that the person is not 
fit to be set at large, the court or judge shall make an order that he be 
detained in custody, or delivered to his kindred or friends, who shall 
be responsible for his safe keeping, and who shall restrain him from the 
commission of any ofi'ence. 

Whenever it shall appear, upon the trial of any person charged with a 
crime or misdemeanor, that such person was insane at the time of the 
commission of the same, and he shall be acquitted by the jury on that 
ground, the court shall have power to order such person to be kept in 
strict custody, in such place and in such manner as to the court seems fit, 
so long as such person continues to be of unsound mind. 

The same proceedings shall be had if any person indicted for an offence 
shall, upon arraignment, be found to be a lunatic by a jury impanelled 
for the purpose ; or if, upon the trial of any person indicted, he appears 
to the jury to be then a lunatic, the court shall have him put in the care 
and custody of some suitable person. If a person found by inquisition 
to be a lunatic or habitual drunkard has not, and if his friends have not, 
money for his support, he shall be kept at the expense of the county. 



NEW YORK.^ 

No person shall be committed to, or confined as a patient in, any 
asylum or institution, public or private, except upon the certificate of 
two physicians under oath setting forth the insanity. The physicians 
must be of reputable character, graduates of some incorporated medical 
college, permanent residents of the State, and have been in practice three 
years. No certificate shall be made except after a personal examination, 
and in a form prescribed by the lunacy commissioner. It must be in the 
prescribed form and bear date not more than ten days prior to the com- 
mitment. The physicians must not be in any way connected with the 
asylum to which the insane person is committed. 

The patient shall not be kept in the asylum more than five days unless 
before or within that time the certificate is approved by a judge or justice 
of a court of record of the county or district in which the alleged lunatic 
resides, and the judge or justice before approving the certificate may in- 

^ Keviscd Statutes of New York, Bunks tfc Brothers, 7th ed. VoL III. pp. 1887, 
1888, 1890, 1899-1938, 2568, 2590, 2649, 2658; Vol. IV., The Code of Civil Pro- 
cedure, pp. 318, 464-468; Code of Crimiiuvl Procedure, pp. 12, 69, 88, 98, 96. 97, 
126, 127, 175; Penal Code, pp. 5, 47, 79, 98. Laws of New York, 1882, Vol. 2. pp: 
109,500; 1883, p. 199. 



496 APPENDIX — XEW YORK. 

stitute inquiry, and. in his discretion, call a jury to determine the question 
of lunacy. There must be a certificate from some judge of a court of 
record, stating that the physicians have the requisite qualifications. 

The superintendent of any institution, public or private, shall, within 
three days of the commitment of any insane person, make a descriptive 
record of his case in a book especially provided for that purpose, and 
keep a record of his condition and treatment, from time to time, including 
the forms of restraint used. He shall also record the circumstances of 
the discharge or death of all patients. 

If a pauper becomes lunatic, the county superintendents of the poor of 
the county or town where he is chargeable may send him to any State 
lunatic asylum by an order under their hands. 

In case the committee or guardian of any lunatic, or his relatives, 
neglect to confine or maintain him, or are not of sufficient ability to do 
so, the overseers of the poor or constable of the city or town where any 
such lunatic shall be found, shall report the same forthwith to the super- 
intendent of the poor, who shall apply to the county judge, special county 
judge, or surrogate, who, being satisfied that it is dangerous for such 
lunatic to go at large, shall order him to be apprehended and properly 
confined, and within ten days taken to some State lunatic asylum, or to 
such other asylum as may be approved by a standing order of the super- 
visor of the county. 

If any person, not a pauper but in indigent circumstances, becomes 
insane, application may be made to any county judge, special county 
judge, judge of a superior court or common pleas of the county where he 
resides, and the judge shall investigate the facts in the case, both as to 
indigence and as to insanity. If the judge finds that there is reasonable 
cause, he shall fix a time and place for a hearing, and give notice to one 
of the superintendents of the poor of the county chargeable with the ex- 
pense of supporting such person in the asylum, and shall then proceed to 
ascertain when such person became insane. The judge may require the 
friends of the patient to give security to remove him from the asylum as 
soon as he shall recover. If such patient has not recovered at the end 
of two years, the managers of the asylum may cause him to be returned 
to the county from which he came. The judge shall file all the papers 
in the case, together with his decision, with the clerk of the county, and 
report the facts to the supervisors, who shall provide the money for the 
support of such indigent lunatic. 

If the expenses in the asylum of an indigent insane patient, not a 
pauper, have been paid by his friends for six months, and the superin- 
tendent shall certify that he is a fit patient and likely to improve, the 
supervisors of the county of his residence are required, upon a sworn ap- 
plication, to defray his expenses for remaining another year. And they 
shall repeat the same for two years more, upon like application, and the 
production of a new certificate from the superintendent. If an}' lunatic, 
or friend on his behalf, is dissatisfied with any final decision of a county 
judge, special county judge, surrogate, judge of the superior court or court 
of common pleas, of a city or police magistrate, in committing to an 
asylum, he may, within three days after such order, appeal to a justice 
of the supreme court, who shall thereupon stay all proceedings, and 



APPENDIX — NEW TOKK. 497 

forthwith call a jury to decide upon the fact of lunacy. If, after a fair 
investigation, aided by the testimony of at least two respectable physi- 
cians, the jury find the person insane, the justice shall confirm the order 
for his being sent immediately to an asylum. 

If any of the judges above mentioned refuse to make an order for the 
confinement of a dangerous insane person, they shall state their reasons 
in writing, so that any person aggrieved may appeal to a justice of the 
supreme court, who shall determine the matter in a summary way, or 
call a jury at his discretion. 

No person committed to any prison, jail, or house of correction, as a 
dangerous lunatic, shall be kept there longer than ten days ; if, at the 
end of that time, he continues to be insane, he shall be sent forthwith to 
some State lunatic asylum, or some other approved asylum. 

If a person found to be a lunatic, or his committee, is not possessed of 
sufficient property to maintain himself, his father, mother, or children, 
if they are of sufficient ability, shall be compelled to provide for and 
maintain him. If such relatives have not sufficient means, then the 
superintendent of the poor of the county shall send such pauper lunatic 
to a State asylum, or to such private asylum as may be'approved by a 
standing order of the supervisors. 

Whenever any person, who is possessed of sufficient property to 
maintain himself, becomes, by lunacy or otherwise, so far disordered in 
his senses as to be dangerous, it shall be the duty of the committee of 
his person and estate to provide a suitable place for his confinement, 
and to confine and maintain him in such manner as shall be approved by 
the proper legal authority ; and in every succeeding attack of lunacy he 
shall be sent, within ten days, to some State lunatic asylum, or to such 
public or private asylum as may be approved by a standing order of the 
supervisors of the county. The superintendents and overseers of the 
poor are severally enjoined to see that this provision is carried into effect, 
as well in cases where the lunatic or his relatives are of sufficient ability 
to defray the expenses as in case of a pauper. 

The overseers of the poor have authority to compel the relatives, 
guardian, or committee of the person and estate, as the case may be, to 
confine and maintain an insane person, at their discretion, and to collect 
the costs of his confinement. 

No pauper who has not resided in the State for at least one year next 
prior to the application shall be committed to any State insane asylum. 

Any soldier or sailor, an inmate of the New York State Soldiers' and 
Sailors' Home, who shall be found insane, may be transferred by an 
order of the president and secretary of the board of trustees and the 
superintendent of the home to any State lunatic asylum, there to remain 
at the expense of said Soldiers' Home until discharged. 

The commissioners of the department of public charities and correction 
of the city of New York may, in their discretion, transfer any insane 
person in their custody or control to any State lunatic asylum, the ofiicers 
of which will consent to receive the same. The expense of maintenance 
shall be paid by said commissioners. 

It shall be the duty of all captains, owners, agents, and consignees of 
all ships or vessels arriving at the port of New York, having as a pas- 



498 APPENDIX — NEW YOKK. 

senger any lunatic, to keep, provide, and care for such person, on board 
such ship or vessel, until such person shall have been delivered over and 
placed under the care of the commissioners of emigration. 

If a person is incompetent to manage himself or his affairs on account 
of lunacy, application may be made to the court having jurisdiction for 
the appointment of a committee of the person, or of the property, or of 
both. The court, if the case seems a proper one, shall make an order, 
either that a commission issue for the purpose of inquiring into the case, 
or that the question be submitted to a jury at a term of the court. If 
the person is found to be incompetent, the court makes such order as 
justice requires. The committee appointed, either of the person or of 
the property, must give security before entering upon his duties. 

If any inmate of any State almshouse, when admitted, is insane, or 
thereafter becomes insane, and the accommodations in the almshouse are 
not adequate and proper for his treatment, the secretary of the State 
Board of Charities may cause his removal to the appropriate State asylum 
for the insane. 

A competent physician shall be appointed by the Governor with the 
consent of the Senate, who shall be designated the State commissioner 
in lunacy. It shall be his duty to visit and examine all the asylums, 
public and private, and report annually to the legislature. If he has 
reason to believe that any person is unlawfully confined or improperly 
treated, or that there is any general mismanagement, he shall make an 
investigation : and he is empowered to summon witnesses, administer 
oaths, and issue orders such as the case may require. He shall notify 
the district attorney, who shall be present at all his investigations into 
matters of general administration and management, to examine witnesses 
in behalf of the people. The commissioner in lunacy shall exercise the 
powers belonging to referees appointed by the supreme court, and he 
may direct the authorities of the asylum, where affairs have been investi- 
gated, to correct any rule or abuses as he thinks best. 

It is also the duty of the lunacy commissioner to grant licenses for 
private asylums ; and any person establishing a private insane asylum 
without such license is guilty of a misdemeanor. If his orders are dis- 
obeyed, the case shall be laid before the supreme court and be by it de- 
cided and disposed of. 

A person is not excused from criminal liability, as a lunatic or insane 
person, except upon proof that at the time of committing the alleged 
criminal act he was laboring under such a defect of reason as either not 
to know the nature and quality of the act he was doing, or not to know 
that the act was wrong. 

If any person in confinement, under indictment for the crime of arson, 
murder, or attempt at murder, or highway robbery, shall appear to be 
insane, the court of oyer and terminer in which the indictment is pend- 
ing may, with the concurrence of the presiding judge of such court, 
summarily inquire into the sanity of such person, and may, for that 
purpose, appoint a commission to inquire into the facts of the case, and 
report to the court ; and if the court find such person insane, or not of 
sufl5cient capacity to undertake his defence, they may remand him to such 
State lunatic asylum as in their judgment is meet, there to remain until 



APPENDIX — NEW YOEK. 499 

restored to his right mind, when he shall be returned to prison for further 
criminal proceedings, unless he be otherwise discharged, according to law. 

If any person is confined under conviction for an offence for which the 
punishment is death, the Governor may inquire into the case, appoint a 
commission, and, if the convict is found insane and irresponsible, may order 
his removal to the State Asylum for Insane Criminals, there to remain 
until restored to his right mind. The medical superintendent of the 
asylum, whenever he thinks the convict is cured of his insanity, shall 
report the fact to the State commissioner in lunacy and to a justice of the 
supreme court of the district where the asylum is situated. If, on inquiry, 
they are satisfied of his recovery, they shall cause the convict to be re- 
turned to the sheriff, to be dealt with according to law. 

Any person charged with arson, murder, or attempt at murder, or 
highway robbery, and confined in either of the State lunatic asylums as 
insane, may, upon the application of any superintendent of an asylum, 
be brought before a justice of the supreme court, who may order his 
removal to the Asylum for Insane Criminals at Auburn ; and convicts 
confined in any penitentiary, if insane, may be removed there, to stay 
until recovered or legally discharged. 

If any person in confinement under any other than civil process appears 
to be insane, the county judge of the county where he is confined shall 
institute an investigation, call two physicians and other witnesses, invite 
the district attorney to aid in the examination, and, if he deem it neces- 
sary, call a jury. If the person is found to be insane, the judge may 
order his removal to a State asylum, to remain until restored. Whenever 
he recovers, he may be remanded to prison for further criminal proceed- 
ings, or, if the period of his imprisonment has expired, he may be 
discharged. The like proceedings may be had in case of an insane 
person imprisoned on civil process ; but notice shall be sent to the 
plaintiff in the case, or to his attorney. 

The defence of insanity must be pleaded in a criminal case at the time 
the prisoner is arraigned. If a defendant is acquitted on the ground of 
insanity, the court, if they deem his discharge dangerous to the public 
peace or safety, must order him to be committed to the State Lunatic 
Asylum until he becomes sane. 

When a defendant pleads insanity, the court may appoint a commission, 
of not more than three persons, to examine the accused, and report to the 
court as to his sanity at the time the crime was perpetrated. The com- 
mission must be attended by the district attorney, and the counsel for the 
defendant may take part in the proceedings. If the commission find the 
defendant insane, the trial must be suspended until he becomes sane ; and 
the court, if it deem his discharge dangerous, must order that he be com- 
mitted to a State lunatic asylum, to remain until cured. When he becomes 
sane, he must be taken from the asylum, and put in proper custody until 
he is brought to trial. 

If a defendant in confinement under indictment at any time, before or 
after conviction, appears to be insane, the court, unless the defendant is 
under sentence of death, may in a like manner appoint a connnission and 
the like proceedings shall be had. 

If, after a defendant has been sentenced to death, there is reasonable 



500 APPENDIX— NEW YORK. 

ground to believe he has become insane, the sheriff, with the concurrence 
of a justice of the supreme court or the county judge of the county, must 
impanel a jury of twelve persons to examine the question of the sanity 
of the defendant. Notice of the trial must be given to the district 
attorney, and he must attend. If it be found by the inquisition that the 
defendant is insane, the sheriff must suspend the execution until he is 
directed by the Governor to proceed. The Governor shall give directions 
for the disposition and custody of the defendant, and, as soon as he is 
satisfied of his restoration to sanity, must direct his execution, pursuant 
to his sentence, unless the sentence is commuted or the convict pardoned. 

No insane person confined in any county poor-house or county asylum 
shall be discharged by the keeper, or by the superintendent of the poor, 
or by any other county authority, without an order from a county judge 
or judge of the supreme court, founded upon evidence that it is safe, 
legal, and right to make such discharge. In New York and Kings 
Counties, however, it shall be sufficient if there is a certificate in writing 
of the physician of the asylum stating that the discharge is safe and proper. 

It is provided, in regard to the Utica Asylum, that no patient shall be 
committed for a shorter period than six months except in special cases. 
Whenever there are vacancies, paying patients may be committed under 
special agreement, in conformity with the law regarding commitments, 
if the cases are recent and promise speedy recovery, or when admission 
is sought under peculiarly afflicting circumstances. 

The managers, upon the superintendent's certificate of complete 
recovery, may discharge any patient except one under a criminal charge 
liable to be remanded to prison. They may discharge any patient com- 
mitted as ''dangerous," or any patient sent by the superintendent or 
overseers of the poor, or by the judge of a county, if the superintendent 
certifies that the patient is harmless and will probably continue so, and is 
not likely to be improved by further treatment. If the asylum is full, 
they may discharge patients manifestly incurable that can probably be 
rendered comfortable in the poor-house, and give preference, in the 
admitting of patients, to recent cases or those of not over one year's 
duration. They may discharge and deliver any patient except one under 
criminal charge, to his relatives or friends, who will give a bond approved 
by the county judge for the patient's peaceable behavior, safe custody, 
and comfortable maintenance without further public charge. A criminal 
lunatic may be discharged by order of one of the justices of the supreme 
court or a circuit judge, when it appears safe, legal, and right to make 
such order. No patient shall be discharged without proper clothing and 
money not exceeding $20 to pay his expenses. 

Insane female convicts at Sing Sing may be removed to the asylum for 
insane criminals at Auburn, to stay until restored to reason, and then be 
returned. Whenever any convict in this asylum for insane criminals 
shall continue to be insane at the expiration of the term for which he was 
sentenced, the board of inspectors, upon the superintendent's certificate 
that he is harmless and is not likely to be improved by further treatment, 
or upon a certificate that he is incurable and can be made comfortable in 
the county almshouse, may cause such insane convict to be removed to 
the county where he was convicted or where he belongs and placed under 



APPENDIX — NORTH CAROLINA. 501 

the care of the superintendents of the poor of such county. Or they may 
deliver such convict, on the expiration of his sentence, to his friends, if 
they will give security for his safe custody and comfortable maintenance 
without public charge. If the insanity continues after the expiration of 
the convict's sentence, he shall be kept in the asylum until adjudged a fit 
subject to be discharged. If any convict confined in said asylum as a 
lunatic is restored to reason and is ready to be sent back to prison, he 
shall be sent to the Auburn State Prison, even though originally sen- 
tenced to some other prison, but any convict received from a penitentiary 
shall be returned to the same. 

The chronic pauper insane from the poor-houses of the counties shall 
be sent to the Willard Asylum by the county superintendents of the 
poor, except from those counties having asylums for the insane to which 
they are authorized to send insane paupers by special legislative enact- 
ment, or those counties exempted by the State Board of Charities. And 
all the chronic insane paupers who may be discharged not recovered from 
the State lunatic asylums, and who continue a public charge, shall be 
sent to the Willard Asylum and paid for by the counties from which they 
are sent. 

The chronic pauper insane from such counties, and in such numbers as 
may be designated by the State Board of Charities, shall be sent to the 
Binghamton Asylum. Any of the patients who are recovered or become 
harmless, may be discharged by the trustees into the care of their 
friends. The trustees may also deliver any patient who has not recovered 
to his friends, on their giving proper security for his custody and main- 
tenance. Harmless patients may also be sent back from this asylum to 
the counties from which they came, and placed in the care of the super- 
intendents of the poor. 

Town or county officials, in committing insane persons, are required to 
send them well provided with clothing and in a cleanly condition. 

Any person found guilty of confining a lunatic in any other manner 
or in any other place than is prescribed by law, is liable to a fine not 
exceeding $250, or imprisonment not over one year, or both, at the dis- 
cretion of the court. 

The terms lunatic and insane include all persons deranged or of unsound 
mind except idiots. 



NORTH CAROLINA.^ 

For commitment to any insane asylum, some respectable citizen, re- 
siding in the county of the alleged insane person, shall file with a justice 
of the peace of the county an affidavit, in prescribed form, stating that he 
has examined the alleged lunatic, and believes him to be insane, and a fit „ 

subject for the asylum. The justice of the peace shall have the supposed f 

1 Laws of North Carolina, 1883, pp. 237-251. 581, 021. 



502 APPENDIX — NORTH CAROLINA. 

insane person brought before him, and shall call to his assistance one or 
more justices of said county, and they together shall proceed to examine 
into the condition of mind of the alleged insane person. They shall take 
the testimony of at least one respectable physician, and such others as they 
may think proper. If any two of the justices decide that the person is 
insane, and no friend is found who will become bound with good security 
to restrain and take care of him until he recovers, the justices shall direct 
that such insane person be removed to the proper asylum as a patient. 
The justices shall make a full report of their proceedings to the clerk of 
the superior court of their county. 

Whenever an insane person shall be conveyed to any asylum, and the 
superintendent is in doubt as to the propriety of his commitment, he may 
convene any three of the directors, who shall examine the matter. If a 
majority of the three so decide, the patient shall be admitted, but three 
directors may at any time deliver the patient to any friend who will 
become bound with good surety to restrain and take care of him. 

Any three of the board of directors of any asylum, upon the superin- 
tendent certifying the facts, may discharge or remove any person admitted 
as insane, w^hen such patient has become of sound mind, or when he is 
incurable, but not dangerous ; or the said directors may permit a patient 
to go to the county of his settlement on probation if the superintendent 
thinks it advisable. 

If an indigent patient is discharged or removed, except as being recov- 
ered, it shall be the duty of the sheriff to take him to his county. If an 
indigent person is discharged recovered, he shall be furnished with money 
to pay his expenses of travel to the county of his settlement. 

All bonds for the safe keeping of insane persons shall be in prescribed 
form, payable to the State of North Carolina, and shall be in the sum of 



Costs and expenses incurred in regard to a patient shall be paid by the 
county, unless the patient or those liable for his support have means to 

If a patient entrusted to a friend is not cared for according to the terms 
of the bond, any two justices of the peace of the county may send the 
patient to the proper asylum, unless some other responsible and discreet 
friend will undertake to take charge of him. 

The board of public charities shall visit the asylum from time to time, 
and make reports to the General Assembly. 

If a person found to be insane has ample means to care for his family 
and himself, and is capable of declaring his preference to be placed in 
some asylum outside the State, or if his guardian declares such prefer- 
ence, and two respectable physicians w^ho have examined him, with the 
justices who made the examination, deem it proper, the said justices and 
physicians may recommend that he be placed in the asylum so chosen. 
The justices shall report the proceedings to the clerk of the superior court 
of the count}' . The clerk shall lay the matter before the judge of the 
superior court of the district where the insane person resides, and, if he 
approves, he shall so declare in writing, which shall be recorded by the 
clerk. The said judge shall appoint some friend of the patient to remove 
him to the asylum designated, and a certified copy of the proceedings 



APPENDIX — OHIO. 503 

shall be a sufficient warrant to authorize such friend to act in the matter 
of his removal. 

In the commitment of patients to the asylums, priority shall be given 
to the indigent ; but the boards of directors may also consider the cura- 
bility of patients. If there is sufficient room, paying patients may be 
received. If a person found insane cannot be at once committed to an 
asylum, and he is dangerous to be at large, and cannot otherwise be 
properly restrained, he may be temporarily committed to the county jail. 
When a patient kept in the county jail is fit to be discharged, it shall be 
the duty of the board of county commissioners, on the presentment of a 
certificate of two respectable physicians, and of the chairman of their 
board stating the fact, to make an order for his discharge. 

The judges of the superior court, in their respective districts, shall 
commit to the proper asylum, if there be room therein, as a patient, any 
person w^ho may be confined in jail, on a criminal charge of any kind, or 
upon a peace warrant, whenever the judge shall be satisfied, by the ver- 
dict of a jury of inquisition, that the alleged criminal act was committed 
while such person was insane, and that such insanity continues ; and also 
any person acquitted upon a criminal charge where, on the trial of such 
person, insanity was relied upon as a defence ; provided, the fact of in- 
sanity was found as a distinct issue to exist at the time of such trial, or 
is so found by a jury of inquisition, as such judge may direct. 



OHIO.^ 

Each county is entitled to send patients to the State asylums in pro- 
portion to its population. No person is entitled to admission unless he 
has lived in the State one year next preceding the date of his application 
and his insanity appeared while he resided in the State. The medical 
superintendent of each asylum shall inform the probate judges of the 
different counties in his district, each month, of the number of patients 
to which each county is entitled, and of the number in the asylum from 
each county. If the quota is not full, the probate judge may, at any 
time, send an acute case conformably to the laws. Patients may be 
transferred from one asylum to another upon the order of the Governor, 
and the recommendation of the medical superintendents of the asylums 
affected. Patients in the asylums shall be maintained at the expense of 
the State. 

For the commitment of patients to asylums, some resident citizen of 
the proper county shall file with the probate judge of the county an 
affidavit, stating that he believes the person in question to be insane, or 

1 Revised Statutes of Ohio, 1880. Second Edition, Revised, Vol. I. pp. 204, 321U 
339, 384; Vol. II. pp. 1505-1509, 1688, 1701, 1702, 1720, 1780, 1736, 1831. Laws 
of Ohio, 1881, pp. 62, 102; 1883, pp. 103, 104, 181. 182. 



504 APPENDIX — OHIO. 

unfit to be at large, on account of insanity, and giving the place of his 
legal settlement. The judge shall order the alleged insane person to be 
brought before him on a day named, which shall be not later than five 
days after the filing of the affidavit. He shall summon witnesses, one of 
whom shall be a respectable physician, and, if the insanity is disputed, he 
shall summon such witnesses as the parties opposing desire. If the 
alleged insane person is not in a fit condition to be brought into court, 
the judge shall visit him personally, and certify that he has ascertained 
the condition of the person by actual inspection, and the proceedings 
shall go on in the absence of such insane person. If the judge, after 
hearing the testimony, is satisfied that the person is insane, he shall 
cause a certificate to be made by the medical witness, which shall set forth 
information on twenty-one prescribed points covering the history and con- 
dition of the patient ; he shall then apply to the superintendent of the 
asylum in the proper district, transmitting copies of the physician's cer- 
tificate and his own finding in the case. If the patient can be received, 
the superintendent shall notify the probate judge, and he shall issue his 
warrant to the sheriff, or some suitable person or persons, to take the 
patient to the asylum. The relatives of the patient shall have the right, 
if they desire it, to convey the patient to the asylum. The receipt of 
the patient shall be endorsed on the warrant, which shall be returned to 
the probate judge and filed with the papers in the case. Before the 
probate judge applies for the commitment of the patient, the medical 
witness must make a certificate that the patient is free from all infectious 
diseases and from vermin. 

The relatives of any person charged with insanity, or who is found to 
be insane, shall in all cases have the right to take charge of and keep 
him ; and, in such case, the probate judge who holds the inquest shall 
deliver the insane person to such relatives. When a patient is sent to the 
asylum, the probate judge shall see that he has the proper amount of 
clothing. 

If the patient cannot be admitted to the asylum, the probate judge shall 
have the sherifi", or some other suitable person, take charge of him, until 
such time as he can be received, and, if necessary, the judge may direct 
the confinement of the patient in the county infirmary or jail, but in a 
room separate from the criminals. The judge shall see that things 
necessary are famished, and, if there is no physician regularly employed 
to attend the jail or infirmary, he may employ one to attend the lunatic. 

If an insane person not entitled to admission to the asylum is at large 
and dangerous, the probate judge may order him to be confined, and 
provided for, either by some suitable person, or in the jail or infirmary, 
as above stated. When the attending physician certifies that such person 
is restored to reason, or that it is no longer necessary to confine him, or 
if his friends agree to take care of him, the probate judge shall order his 
discharge. Immediately after the removal, death, escape, or discharge 
of any patient, or return of an escaped patient, the superintendent 
shall notify the probate judge of his county; and he shall also, in case 
of death, notify one or more of the relatives of the deceased patient. 

Incurable and harmless patients may be discharged by the superinten- 
dent and one trustee when it is necessary to make room for a recent case 



APPENDIX — OHIO. 505 

from the same county. The superintendent shall notify the probate judge, 
■who shall by his warrant order the removal of the patient to the township 
of which he is an inhabitant. When a patient is discharged as cured, the 
superintendent may furnish him with suitable clothing and money not 
exceeding $20. 

If a patient discharged as cured becomes a second time insane, the 
facts shall be set forth in an affidavit by a respectable physician, and the 
probate judge shall make application to the superintendent of the proper 
asylum for his commitment. The same proceedings shall then be had as 
in case of a person found insane upon inquest held for the purpose, as 
above stated. 

In the admission of patients, selection shall be made as follows : (1) 
Recent cases (of less than a year's duration). (2) Chronic cases present- 
ing the most favorable prospect of recovery. (3) Those for whom appli- 
cations have been longest on file, other things being equal. (4) No 
county shall have more than its due proportion of patients, unless there 
is some other county in the district without patients enough to fill its 
quota. 

If the friends of a patient ask for his discharge from the asylum, the 
superintendent may require a bond for the safe keeping of such patient ; 
but no patient charged with, or convicted of, homicide, shall be discharged 
without the consent of both the superintendent and the board of trustees 
of such asylum. 

The commissioners of every county in which there now is, or may here- 
after be established, a county infirmary, shall provide separate apartments 
for the safe keeping and treatment of lunatics and idiots who have not 
been, and cannot be, received into either of the lunatic asylums, or who 
have been discharged therefrom. The directors of the infirmary shall 
provide for the safe keeping, support, and treatment of patients who are 
a charge upon the county, and for the treatment and care of such lunatics 
in their county as may be admitted as pay patients, under regulations 
made by the directors. When rooms are provided in the county infirmary, 
insane persons in the county jail shall be transferred to such infirmary. 

The directors of the Ohio Penitentiary shall provide a suitable depart- 
ment for the reception of lunatic or insane convicts, to accommodate the 
convicts that become insane therein. 

If at any time before the indictment of a person confined in jail 
charged with an offence, notice in writing be given by any citizen to the 
sheriff or jailer that such person was insane or an idiot at the time the 
offence was committed, or has since become insane, the sheriff or jailer 
shall forthwith notify the probate judge, clerk, and prosecuting attorney of 
the proper county, and an examining court shall be held ; and if the judge 
find that such person was an idiot when he committed the oftence, or was 
then and still is insane, or afterwards became and still is insane, he shall, 
at his discretion, proceed as [in the case of a person found insane by 
inquest held. When such lunatic is restored to reason, the prosecuting 
attorney shall have him recommitted to the jail to answer the offence 
charged against him. If the prosecuting attorney fiiils to do this, the 
superintendent of the asylum or infirmary shall di'scliargo such patient. 



506 APPENDIX — OHIO. 

When a person is under indictment, or held for trial or sentence, and it 
is suggested to the court that the person is not then sane, and the certifi- 
cate of a respectable physician to the same effect is presented to the court, 
proceedings shall be had to try his sanity, and the question may be sub- 
mitted to a special jury. If the person is found insane, the probate judge 
shall be notified, and shall deal with him as an insane person found so by 
inquest, and upon recovery he shall be brought to trial or sentence. If 
the patient is discharged into the care of his friends, the bond given for 
his support and safe keeping shall contain a condition that he shall, when 
restored to reason, answer to the offence charged in the indictment, or of 
which he has been convicted, at the next term of the court thereafter. 

When a person tried upon an indictment is acquitted on the sole ground 
that he was insane, that fact shall be certified by the clerk to the probate 
judge, and the defendant shall not be discharged, but shall be proceeded 
against as insane, and the verdict shall be 'primd facie evidence of in- 
sanity. 

When a convict in the penitentiary becomes insane, the warden shall 
give notice to the physician for the prison and the superintendent of the 
Columbus Asylum for the Insane, who shall examine the convict, and, if 
they find him insane, shall certify the fact to the warden, w^ho shall forth- 
with put the insane convict in the department prepared for that purpose. 

Such insane convicts shall be treated by the physician and by the 
superintendent of said asylum, and when they are restored, or it is safe 
for them to work, they shall again be put at hard labor, according to their 
sentence. If a convict is insane at the expiration of his term of imprison- 
ment, the probate judge of the county from which he was sent shall take 
him in charge, and order him to be confined, or otherwise disposed of 
and provided for, as directed by law. 

If a convict, at any time before the full execution of his sentence, be 
represented to the Governor of the State to be insane, the Governor shall 
inquire into the facts. If he thinks it proper, he may pardon the convict, 
or commute the sentence, or suspend its execution for a definite time, or 
from time to time. He may order the convict to be confined in the 
penitentiary, or a jail, or conveyed to an asylum for the insane for treat- 
ment. 

If the sentence is suspended, and the convict recover his reason, the 
sentence shall then be fully executed. 

If a convict sentenced to death appears to be insane, the sherifi" shall 
give notice to a judge of the court of common pleas of the judicial dis- 
trict, and shall summon a jury of twelve men. The judge, clerk, and 
prosecuting attorney shall attend the inquiry, and, if it be found that the 
convict is insane, the judge shall suspend the execution. The Governor 
shall be notified of the finding, and may, as soon as he is convinced that 
the convict has recovered, issue a warrant directing his execution. 



APPENDIX — OKEGON. 507 



OREGON. 



The insane have been kept under the care of a contractor, the Btate 
paying a certain sum per week for the board of each patient. 

The county judge, upon application of any two householders in his 
county in writing, under oath, setting forth that any person by reason of 
insanity is suffering from neglect, or is unsafe to be at large, shall cause 
such insane person to be brought before him, and shall cause to appear, at 
the same time and place, two or more competent physicians, and the 
prosecuting attorney of the district, or his deputy, or, in the event of his 
absence, some practising attorney to represent the State. If the physi- 
cians, after careful examination, shall certify on oath that the person is 
insane or idiotic, and the county judge shall find, on the certificate and 
the testimony produced, that the person is insane or idiotic, he shall 
cause the insane person to be conveyed to, and placed in charge of, the 
party or parties contracting to keep and care for the insane and idiotic 
of the State. An appeal may be taken from the decision of the county 
judge in the same manner as is provided for appeal from the judgment of 
county courts in other cases. The appeal may be taken either by the 
householders making application, or by some one on behalf of the alleged 
insane person, or by the prosecuting attorney on behalf of the State. 

The judge shall make inquiry, and, if he finds that the person found 
insane has any property, he shall appoint a guardian to take care of the 
same, and said estate shall be applied to supporting the family of the 
insane person and to paying the expenses of his commitment and support. 
All the proceedings shall be recorded in the county court, and, if the 
patient is adjudged insane, a warrant shall be made reciting the findings 
of the judge, the causes of the insanity when ascertained, and the name, 
age, nativity, and present residence of the patient. The county judge 
shall designate some proper person or persons to take the patient to the 
asylum. Paying patients shall pay according to the terms made with 
the contractors. 

The Governor is required to visit and examine the insane confined by 
law once every six months. He shall also appoint a physician who shall 
visit and inspect the institution where they are kept as often as once 
every month, and oftener if necessary. He shall see that the terms of 
the contract made with the State are fully carried out. He shall have 
power to discharge any patient when he considers that he is cured. In 
case of a disagreement between the physician and the contractor as to 
the sanity of a patient, the Governor may employ some other physician 
to consult upon the case. Whenever a patient dies, or is ordered to be 
discharged by the physician, the Governor and the Secretary of State 
shall be notified, and no board shall be paid after the date of the patient's 
death or the order for his discharge. 

The courts of the State shall have power to commit to tlio care (^f the 

' General Laws of Oreo-on, 1843-1872, pp. 361, 364, 620-6 2;?. L;uvs ol' Oreoon, 
1878, pp. 71-77; 1880, pp. 49-51 ; 1882, pp. 4-6. 



508 APPENDIX — PENNSYLVANIA. 

contractors any person who has been charged with an offence punishable 
with imprisonment or death, who shall have been found to be insane or 
idiotic, and who continues to be insane or idiotic. 

If the defence in any criminal case be the insanity of the defendant, 
and he is found not guilty on that ground, the court must, if it deems his 
being at large dangerous, order him to be committed to any lunatic 
asylum authorized by the State to receive and keep such persons until 
he becomes sane, or is discharged according to law\ 

Whenever any convict confined in the State Prison shall, in the opinion 
of the physician of the prison, be insane or idiotic, the physician shall 
make oath to the same before the county judge of the county in which 
the prison is located. The judge shall summon one or more competent 
physicians to make an examination, and, if in their opinion the convict 
is of unsound mind, the judge shall report the case to the Governor, who 
may, in his discretion, cause the convict to be removed to the place pro- 
vided for the insane and idiotic. 



I 



PENNSYLVANIA.^ 

The trustees of any asylum for the insane where there are women de- 
tained may appoint a skilful female physician to have charge of the female 
patients. 

The Board of Public Charities shall appoint a committee of five of its 
members to act as the committee on lunacy. One of this committee shall 
be a member of the bar, and one a practising physician, and each shall be 
of at least ten years' standing in his profession. The committee on lunacy 
shall examine into the condition of the insane throughout the State, and 
into the management of the hospitals, public and private, and all other 
places in which the insane are kept for care and treatment or detention, 
and shall make an annual report. The board, among other things, shall 
have power, with the consent of the chief justice of the supreme court 
and of the attorney-general, to make rules and regulations : 

1. For the licensing of all asylums and places where more than one 
patient is kept, excepting jails and such hospitals as may be specially ex- 
empted from the duty of obtaining a license. 

2. For securing the proper treatment of all insane persons wherever 
kept, and to guard against the improper detention of such persons. 

3. For determining the forms to be observed in committing, trans- 
ferring, and discharging all lunatics except those committed by order of 
a court of record. 

i Brightlv's Purdon's Digest of Laws of Pennsylvania, 1700-1872, Yol. 1, pp. 27, 
391, 392. Vol. 2, pp. 969-989. Purdon's Annual Digest, 1873-1878, pp. 1893, 1894^ 
Laws of Pennsylvania, 1879, p. 98; 1881, pp. 83, 84, 173 ; 1883, pp. 21-30, 92. 



APPENDIX — PENNSYLVANIA. 509 

There shall be appointed in each county where there is a house or 
place for the care or detention of the insane a board of visitors of not 
less than three persons. Women may be appointed members of these 
boards. 

The board of public charities shall make rules to insure to the patients 
the admission to see them of all proper visitors, being members of their 
family, friends, agents, or attorneys. 

No person shall be received as a patient for treatment or for detention 
into any house or place where more than one insane person is detained, 
or into any house or place where one or more insane persons are detained 
for compensation, without a certificate signed by at least two physicians, 
residents in the commonwealth, who have been in the practice of medicine 
for at least five years, stating that they have examined separately the 
person alleged to be insane and believe that he is insane, and that the 
disease is of a character which requires that the person should be placed 
in a hospital or other establishment for care and treatment ; that they 
are not related by blood or marriage to the patient, nor in any way con- 
nected with the hospital in which it is proposed to place him. This 
certificate must be made within one week after the examination of the 
patient, and within two weeks of the time of his admission to the hos- 
pital. It shall be sworn to before a judge of the county where the ex- 
amination took place, and the judge shall certify to the genuineness of 
the signatures, and to the standing and good repute of the signers. 

The person or persons requesting the admission or detention shall sign 
a writing stating that the person has been removed, and is to be detained 
at his or their request under the belief that such detention is necessary 
and for the benefit of the insane person. There shall also be furnished 
to the persons in charge of the hospital or house a statement signed by 
the persons requesting the detention of the patient, giving his name, age, 
residence, occupation, and a list of his relatives, also the circumstances 
connected with the patient's insanity, and the names and address of his 
medical attendants for two years. 

If, through inadvertence, any of the answers are omitted, and there is 
no reason to doubt the. good faith of the parties, the patient may be 
received and kept, if within seven days the statements are made complete. 
The regular medical attendant of the house shall, within twenty -four hours 
after the reception of any patient, examine him, and in case he is of opinion 
that a detention is not necessary for the benefit of the patient, he shall 
notify the person or persons at whose instance the patient is detained, 
and unless within seven days satisfactory proof is exhibited of such 
necessity the patient shall be discharged and restored to his family or 
friends. At the time of such examination the medical attendant shall 
inform the patient that if he desires to communicate with any person or 
persons they will be summoned, and any proper person or persons, not 
exceeding two, shall be permitted to have a full and unrestrained inter- 
view with the patient. 

The statements furnished at the time of the reception of the patient, 
and the statement of the medical attendant of the liouse, shall be sent to 
the committee on lunacy, and there shall be a report, at least once in six 
months, by the medical attendant, on the condition of each patient. 



510 APPENDIX — PENNSYLVANIA. 

Persons detained as insane may, under certain restrictions and regula- 
tions, have any medical practitioner they desire to treat them for all 
maladies other than insanity. 

All persons detained as insane shall, in the discretion of the superin- 
tendent, be allowed to correspond under seal with persons outside the 
asylum, and they shall have the unrestricted privilege of writing once a 
month to any member of the committee on lunacy. 

All persons other than criminals, who have been detained as insane, 
shall, as soon as they are restored to reason, in the opinion of the medical 
attendant of the house, be forthwith discharged. If the discharged 
patient is in indigent circumstances, he shall be furnished with raiment 
and with funds sufficient to travel to his home. 

The committee on lunacy shall be notified of all discharges Avithin 
seven days thereafter. 

The committee on lunacy may at any time order the discharge of a 
patient (other than a person committed after trial and conviction for 
crime, or by order of court). But such order shall not be made unless 
notice is first given to the person in charge of the asylum, and to the 
persons who caused the patient to be detained, and the committee shall 
not sign an order for discharge unless they have personally examined the 
case of the patient. 

Persons may voluntarily place themselves in an asylum for a period 
not exceeding seven days, by signing an agreement giving authority to 
detain them, and they may from time to time renew^ the authority for 
periods not exceeding seven days each ; but every such agreement must 
be signed in the presence of some adult person attending as a friend of 
the patient. Such agreement must also be signed in the presence of the 
person in charge of the house, or the medical attendant, who shall him- 
self subscribe it. 

Whenever the State Board of Commissioners of Public Charities shall 
deem it expedient to transfer any indigent insane person in a county 
poor-house, or almshouse, or otherwise in the custody of the directors or 
overseers of the poor, to the State hospitals for the insane for care and 
treatment, they shall petition the president judge of the court of common 
pleas of the proper county, who shall notify the directors or overseers of 
the poor to appear, and show cause why such removal should not take 
place. If, upon hearing, the judge deem it best, he shall make an order 
directing the removal of such insane person to the State hospital for the 
proper district. 

The expense of caring for indigent insane persons in the State hos- 
pitals shall be divided between the State and the county, the county not 
paying for each person over two dollars a week. 

Insane persons may be placed in a hospital by order of any court or 
law judge after the following course of proceedings : On statement in 
writing of any respectable person that a certain person is insane, and 
requires restraint, the judge shall appoint at once a commission to inquire 
into, and report on, the facts of the case. This commission shall be com- 
posed of three persons, one of whom, at least, shall be a physician, and 
another a lawyer. If, after hearing the evidence, they think it is a suit- 



APPENDIX — PENNSYLVANIA. 611 

able case for confinement, the judge shall issue his warrant for such dis- 
position of the insane person as the circumstances of the case require. 

If an insane person is manifestly suffering from want of proper care, 
any law judge shall order him to be placed in some hospital for the 
insane, at the expense of those legally bound to support him. But in 
every such case there muse be notice to the persons affected, and a hearing 
had in the matter. Persons who have voluntarily bound themselves for 
the support of any patient in the hospital, may remove the patient to 
avoid further responsibility. 

Pennsylvania State Lunatic Hospital. — The admission of insane 
patients from the several counties shall be in the ratio of their insane 
population. Paying patients shall pay according to the terms directed 
by the trustees. Indigent persons and paupers shall be supported in the 
hospital by the townships and counties to which they are chargeable. 
The several constituted authorities having care of the poor in the several 
counties and towns shall have authority to send to the asylum such insane 
paupers as they deem proper inmates. 

If any person shall apply to any court of record, having jurisdiction 
of offences which are punishable by imprisonment for ninety days or 
more, for the commitment to the asylum of any insane person within the 
county, it shall be lawful for such court to either inquire into the fact of 
insanity in a summary way, giving due notice to the alleged lunatic and 
his friends or kindred, or by awarding an inquest, at the option of the 
court. If the court is satisfied that such person is by reason of insanity 
unfit to be at large, or is suffering any unnecessary duress or hardship, 
it shall commit the person to the asylum ; but in all cases the court may 
use its discretion in sending any insane person to the hospital, and may 
cause him to be confined elsewhere if it believes the case incurable. In 
order of admission, the indigent are to have precedence over the rich, 
and if there is not room for all, recent cases shall have preference over 
those of long standing. 

The friends or relatives of any insane person, a patient in the hospital, 
may apply to the court of common pleas of Dauphin County, or to the 
president judge of said court in vacation, to deliver over to them the 
person there confined. The court or judge, if it is safe for the com- 
munity, may do this, provided security is given that such lunatic shall 
do no injury to the person or property of anyone when at large. 

The courts may commit to the asylum any person who, having been 
charged with an offence punishable by imprisonment or death, shall be 
found to have been insane at the time the offence Avas committed, and 
Avho still continues insane. 

If any prisoner confined in the Eastern Penitentiary develops such 
marked insanity as to render continued confinement in the penitentiary 
improper, and removal to the State Lunatic Hospital necessary to hi's 
restoration, the inspectors of the penitentiary shall submit the case to a 
board composed of the district attorney of the county of Philadoljihia, 
the principal physician of the Pennsylvania Hospital for the Insane at 
Phikdelphia, and the principal physician of the Friends' Insane Asylum 
at Frankford, and in case a majority cannot at any time Avhen required 
attend, a competent physician or physicians shairbo appointed by the 



512 APPENDIX— "PENNSYLVANIA. 

court of quarter sessions of the county of Philadelphia in the place oi 
such as cannot attend. If any two of the board certify that the prisoner 
is insane, the Governor shall, if he approves, direct that the insane pris- 
oner be removed to the State Lunatic Hospital. If any such insane 
prisoner in the hospital so far recovers, before his sentence has expired, 
that his return to the penitentiary will be safe and proper, the trustees 
shall cause such prisoner to be returned to the penitentiary. Due notice 
of all such removals or transfers shall be given to the clerk of the court 
of quarter sessions of the county from which such prisoners were sent to 
the penitentiary. 

No person shall be sent to this lunatic hospital who shall have been 
charged with homicide, or of having attempted to commit the same, or to 
commit any arson, rape, robbery, or burglary, and have been acquitted of 
any such oifence on the ground of insanity. Where the court trying- 
such person, or hearing the case, shall be satisfied that it is dangerous for 
such lunatic to be at large on account of having committed or attempted 
to commit either of the crimes aforesaid, such person shall be continued 
in the penitentiary or the prison of the county ; provided that the court 
may send the person to said lunatic hospital, if it is satisfied that a cure 
of the insanity may be speedily efiected by so doing. 

In every case of an insane criminal or a dangerous lunatic sent to the 
asylum, if the trustees of the asylum and the superintending physician 
are satisfied there is no reasonable prospect of a cure of the insanity 
being efiected by a retention of the lunatic in the hospital, they shall 
cause him to be removed to the prison of the proper county, or to the 
penitentiary from which he was sent. 

Weste^m Pennsylvania Hospital. — Beside provisions in substance the 
same as those in regard to commitment to and discharge from the Penn- 
sylvania State Lunatic Hospital, it is further specially provided as 
follows : Any indigent insane patients, not criminals, that are regarded 
by the board of managers of the hospital and the physician as incurable, 
shall be returned to the constituted authorities having charge of the poor 
in the city, township, or poor district, which may be chargeable with the 
support of such poor patients. If any criminal a patient in the hospital 
recovers his sanity, the sherifi" shall be notified, and thereupon such 
sherifi" shall remove such person to the jail of the proper county, there 
to be held in strict custody subject to the further order, decree, or sentence 
of the court by which he was committed to the hospital. If any indigent 
patient is cured of his insanity, the principal physician shall notify the 
commissioners of the proper county to remove such cured person from the 
hospital. 

If any county liable for the support of insane patients fails for a 
period of three months to pay the amount due for such support, the 
managers of the hospital may return to the jail of the said county those 
insane persons whose expenses remain unpaid, excepting those cases 
which have been sent to the hospital from the penitentiary. 

Miscellaneous Provisions. — It shall be lawful for any court of common 
pleas to issue a commission to inquire into the lunacy of any person in 
the commonwealth, or having property therein. On the return of any 
inquisition finding that the person named is a lunatic, the court may 



APPENDIX — PENNSYLVANIA. 513 

commit the custody and care of the person, or estate, or both, to such 
person or persons as they deem most suitable. Whenever any person 
shall be found by inquisition to be insane, the committee of the person 
or of the estate of such insane person, and also the clerk of the court 
into which the inquisition has been returned, shall forthwith send to the 
committee on lunacy a statement signed by the committee of the lunatic 
giving the name, age, sex, and residence of the lunatic, and the residence 
of the committee ; and, upon any change in the residence or place of 
detention of the lunatic, notice shall forthwith be given to the committee 
on lunacy. The committee on lunacy shall have power to visit, examine, 
and look after such lunatic, and may apply to the proper court to make 
such orders for the care or maintenance of the lunatic as the case may 
require. Appeal from any order thus made may be taken to the supreme 
court. Adjudged lunatics shall not be arrested on civil process, and, if 
they are so arrested, shall be discharged by the court from which the 
process issued. 

If any person not an adjudged lunatic is imprisoned in any civil action 
and appears to be insane, the jailer shall notify two or more aldermen or 
justices of the peace, who shall attend at the jail and make an examina- 
tion, and, if they find the prisoner of unsound mind, they shall certify 
the same to the prothonotary of the court of common pleas of the county. 
He shall bring the matter before the court, and a day shall be fixed for a 
hearing, and the creditor, plaintiff in the case, shall be notified. If the 
court, on hearing the case, is satisfied that the prisoner is insane, an 
order shall be made for his discharge from confinement ; provided that if 
it appears to the court that he is not fit to go at large, the court may make 
an order that he be detained in custody or delivered to his kindred 
or friends in the manner provided in the case of a lunatic charged with a 
crime or misdemeanor. 

Whenever upon the trial of any person charged with a crime or mis- 
demeanor it is given in evidence that such person was insane at the time 
of the commission of such offence, and he is acquitted by the jury 
especially on this ground, the court may order him to be committed to some 
place of confinement for safe keeping or treatment. If after a confinement 
of three months any law judge is satisfied that the prisoner has recovered, 
and that the paroxysm of insanity in which the criminal act was com- 
mitted was the first and only one he had ever experienced, he may order 
his unconditional discharge ; if, however, it appear that such paroxysm 
of insanity was preceded by at least one other, then the court may in its 
discretion appoint a guardian of his person and commit the care of tlie 
prisoner to him, the guardian giving bonds to pay for any damage 
his ward may commit ; provided always, that in case of homicide, or 
attempted homicide, the prisoner shall not be discharged unless, in the 
unanimous opinion of the superintendent and the managers of the hospital 
and the court before which the prisoner was tried, he has recovered and 
is safe to be at large. If a person indicted for an oftence shall, upon 
arraignment or upon the trial, be found to be a lunatic, the court shall 
proceed to confine him as above stated. In every case in which a person 
charged with any otTcnce is brought before the court to bo discharged for 
want of prosecution, and shall, by the oath of one or nun-e credible jiersons, 

33 



514 APPENDIX — PENNSYLVANIA. 

appear to be insane, the court shall order the district attorney to send 
before the grand jury a written allegation of such insanity, and the grand 
jury shall make inquiry into the case, and make presentment of their 
finding, and thereupon the court shall order a jury to be impanelled 
to try the insanity of such person. Notice of the trial shall be given to 
the next of kin, and, if the jury find such person insane, he shall be 
committed by the court as aforesaid. 

If the kindred or friends of any person who may have been acquitted 
as aforesaid on the ground of insanity, or, in default of such kindred or 
friends, the guardians, overseers, or supervisors of any county, township, 
or place, shall give proper security that such lunatic shall be restrained 
from the commission of any oifence, the court may make an order for his 
delivery to his kindred or friends, or to such guardians, overseers, or 
supervisors. 

Whenever any person is imprisoned, either convicted of any crime, or 
charged with any crime, and acquitted on the ground of insanity, appli- 
cation in writing, under oath, stating that such prisoner is believed to be 
insane, and requesting that such prisoner be removed to a hospital for 
the insane, may be made to any judge of any court having immediate 
cognizance of the crime with which such prisoner is charged, or of the 
court by which such prisoner has been convicted, to appoint a commission 
of three citizens. One of the commissioners shall be of the profession of 
medicine and one of the profession of law, and it shall be their duty to 
inquire into and report upon the mental condition of the prisoner. If, 
by the report of the commissioners, it appears that the prisoner is of 
unsound mind and unfit for penal discipline, the judge issuing the com- 
mission, or any other judge of the same court, may make an order di- 
recting the removal of such prisoner to the State Hospital for the Insane 
nearest to the place of imprisonment, there to be kept and cared for : 
Provided, that whenever a hospital is established by the State especially 
for the care of insane crimicals, the order of removal shall be to that 
hospital. 

In all cases where any person who may have committed any criminal 
act and is dangerous to the community shall be found to be insane in the 
manner provided by law, any court having cognizance of the offence with 
which such person is charged may commit him to the proper asylum for 
the insane, to remain until restored to sanity. 

Whenever any person sent to the hospital under these provisions has 
been so far restored to mental sanity as no longer to need the care or 
restraint of the hospital, the judge w^ho committed him may, if the term 
of imprisonment for which such prisoner was sentenced has not expired, 
remand him to prison to serve out the unexpired term of sentence, or if 
such prisoner became unsound in mind after the alleged crime and before 
conviction, the judge may remand such prisoner for trial ; but, if the 
term for which such prisoner was sentenced has expired, or if the crime 
w^ith which the prisoner is chare, ed was committed during his probable 
insanity, the judge may order the patient to be discharged. If the term 
of sentence expires while the prisoner remains uncured in the hospital, 
the judge, upon the due application of relatives or friends of such patient, 
and upon proper security being given for the custody and care of such 



APPENDIX — EHODE ISLAND. 515 

insane person, may make an order for his discharge from the hospital 
and delivery into the control of the person or persons applying therefor. 

Insane criminals in custody shall not be received into an asylum except 
when delivered by a sheriff of the county, or his deputy, together with an 
order of the proper court. Nor shall such criminals be discharged from 
a hospital, or other place of detention, save on a like order, and to the 
sheriff, or his deputy, producing the order. 

Whenever any person detained in any jail or prison is insane, or in 
such a condition as to require treatment in a hospital for the insane, it 
shall be the duty of any law judge of the court, under whose order the 
person is detained, upon application, to direct an inquiry into the circum- 
stances, either by a commission or otherwise, as he shall deem proper, 
with notice to the committee on lunacy ; and, if the judge shall be satisfied 
that the prisoner requires treatment in a hospital, he shall direct the re- 
moval of the person from the jail or prison to a State hospital. 

The trustees, managers, and physician of any hospital in which a 
criminal is confined by order of any court, or to which a lunatic has 
been committed after an acquittal of crime, shall not discharge the 
prisoner, or lunatic, without the order of a court of competent jurisdic- 
tion ; and in case such lunatic, whether a convict or acquitted, is not set 
at large, but is to be removed to any place of custody other than a hos- 
pital, the order for removal shall not be made without notice to the com- 
mittee of lunacy, and time given them to investigate the case and be 
heard. 



RHODE ISLAND.! 

Whenever any person is a lunatic, or so furiously mad as to render it 
dangerous for him to be at large, any trial justice or clerk of a justice 
court within the county, on complaint in writing, under oath, shall issue 
his warrant, directing that such person be brought before that or some 
other justice court for examination. If the court, on such examination, 
find the complaint true, it shall, unless security is given that said insane 
person shall not be permitted to go at large until restored to soundness 
of mind, commit such person either to the Butler Hosj^tal for the Insane 
or to the State Asylum for the Insane. Such patient shall be detained 
in the hospital until it is found by some justice court of the county where 
he is detained that he is restored to soundness of mind, or is no longer 
under need of restraint, or until security is given to the court, as afoi'e- 
said, for his safe keeping. The expense of caring for any such lunatic 
shall be paid out of his estate, if he has any; if "he has iio estate, then 
by the town liable for his support. 

» Public Statutes of Rhode Island, 1882, pp. 195-204, 425, 430, 440. 4f)7, 720. 
Acts and Resolves, R. I., January session, 1883, pp. 120, 130, 146. 



616 APPENDIX — RHODE ISLAND. 

On petition, stating that any person is insane, and ought to be placed 
in a hospital, or restrained, any justice of the supreme court may forth- 
with appoint not less than three commissioners to inquire into and report 
all facts bearing on the case, together with their opinion whether such 
person, if insane, should be placed in one of the insane asylums. The 
commissioners shall fix a time for a hearing, give notice to the party 
alleged to be insane, hear all evidence offered, and make an examination 
of the supposed insane person. The court may, pending the inquisition, 
give directions for the care and restraint of such insane person, and may, 
if necessary, commit him to one of the asylums, or to the county jail, as 
is most convenient and proper. On the coming in of the report of the 
commissioners, the justice may order the person complained of to be con- 
fined in the Butler Hospital for the Insane, or at the State Asylum for 
the Insane, or in some other curative hospital for the insane of good 
repute within or without the State, or may dismiss the petition altogether. 

Any person thus committed may, although not restored to sanity, be 
discharged from the asylum upon the written recommendation of the 
trustees and superintendent of the asylum, by an order of any justice of 
the supreme court, made in his discretion. 

The parents or guardian of any insane person, if he have any, and, if 
not, his relatives and friends, or, if a pauper, the overseers of the poor 
of the town to which he is chargeable, may have him removed to and 
placed in the Butler Hospital or State Asylum for the Insane, if he can 
be there received ; and if not, in any other hospital for the insane of 
good repute, managed under the supervision of a board of officers ap- 
pointed under the authority of this or some other State ; but the super- 
intendent of such hospital shall not receive any person into his custody 
in such case without a certificate from two practising physicians of good 
standing that such person is insane. 

Any persons who, of their own accord, without any obligation imposed 
by law, have become responsible for the payment of the expenses of any 
insane person in an asylum, may, if it is necessary in order to terminate 
further responsibility on their part, remove such person therefrom. 

The superintendent of any asylum for the insane within the State 
may, on the application of any relative or friend, and with the approba- 
tion in writing of the visiting committee of the trustees, discharge any 
person not committed by process of law. 

On petition to a justice of the supreme court by some person, not an 
inmate of the asylum, setting forth that he has reason to believe, and does 
believe, that a person confined therein is not insane, and is unjustly de- 
prived of his liberty, the justice, in his discretion, may issue a commission, 
such as has been described above, to inquire into the patient's condition. 
No person shall visit or examine the patient, except the commissioners, 
and they only at the asylum, and not elsewhere. On the coming in of 
the commissioners' report, the court may confirm or disallow the same, 
and order the discharge of such person, or dismiss the petition altogether, 
as the truth shall seem to require. It is not intended by any of these 
provisions to impair or abridge the right to the writ of habeas corpus. 
No commission for the purpose of committing or discharging an insane 
person shall be issued by a justice of the supreme court, as above stated. 



APPENDIX — RHODE ISLAND. 517 

until the person applying therefor has given security for the payment of 
all expenses of the proceedings, and for the support of the insane person 
in the asylum, if committed thereto. 

Whenever any person imprisoned, awaiting trial, in a criminal case, is 
deemed insane, the Agent of State Charities and Corrections, or the clerk 
of the supreme court or court of common pleas, in any county of the 
State other than the county of Providence, may petition any justice of 
the supreme court to make an examination. If, upon such examination, 
the justice is satisfied that the person thus imprisoned is insane or idiotic, 
he may order the removal of such prisoner from the jail to the State 
Asylum for the Insane, if he can be there received ; if not, to the Butler 
Hospital for the Insane. Upon the restoration to reason of any person 
so removed, any one of the justices of the supreme court, in his discre- 
tion, may order that the prisoner be remanded to the place of his original 
confinement, to await his trial for the offence for which he stands com- 
mitted. 

Whenever, on the trial of any person upon an indictment, the accused 
shall set up in defence his insanity, and the jury shall acquit him on that 
ground, the court, if it deem the going at large of such -person dangerous 
to the public peace, shall certify its opinion to the Governor of the State. 
The Governor may make provision for the support of the person so 
acquitted, and cause him to be removed to the State Asylum for the 
Insane, or other institution for the insane, either within or without the 
State, during the continuance of such insanity. The expenses of his 
maintenance shall be paid by the State, but may be collected out of the 
estate of such insane person, if he has any. 

On petition of the Board of State Charities and Corrections, stating that 
any person convicted of crime, and imprisoned for the same in the Stafe 
Prison, or in the Providence county jail ; or, on petition of the clerks of 
the supreme court or court of common pleas, in the other counties of the 
State, that any convict in the jails of their respective counties is insane, 
idiotic, or in such a state of impairment of body, or mind, or both, as 
tends directly to insanity, idiocy, or dementia, or to a permanent incapa- 
city for mental or physical labor, any justice of the supreme court may, 
in his discretion, order an examination. If, upon such examination, said 
justice is satisfied that the convict is insane, or in any of the states of 
mind or body above mentioned, he may order the removal of such pris- 
oner from the State Prison, or any of the said jails, to the State Asylum 
for the Insane, the State Almshouse, or to Butler Hospital, as, in his 
judgment, he shall deem best. Such order of removal shall be only 
during the term, and until the expiration of the prisoner's sentence. 

Upon restoration to reason or to health, both of body and mind, of the 
prisoner, either of the justices of the supreme court may, in his discre- 
tion, remand him to the place of his original confinement, to serve out 
the remainder of his term of sentence. 

The Agent of State Charities and Corrections and the Secretary of State 
shall constitute a commission to visit and examine all phices and institu- 
tions in the State where insane persons are confined, and to receive and 
examine all complaints, communications, and letters from, or relating to, 
any insane person, or person alleged to be insane. They shall investiojate 



518 APPENDIX — SOUTH CAROLINA. 

any case that seems to require it, and, in their discretion, may petition a 
justice of the supreme court to have an examination made of any person's 
condition, in the manner above described, and said justice may, in his 
discretion, cause the person restrained to be discharged. 

Whenever the Agent of State Charities and Corrections shall make 
complaint, in writing, to the supreme court that any person reputed to 
be idiotic, lunatic, or insane, is not humanely or properly cared for, or is 
improperly restrained of his liberty, in any town, the court shall examine 
into the circumstances of the case, and, if the complaint is found true, 
shall order and cause such idiotic, lunatic, or insane person to be removed 
to the State Asylum for the Insane. 

Every pauper lunatic, having no legal settlement in the State, w^ho, in 
the opinion of the Board of State Charities and Corrections, is insane, shall 
be sent by said board to the State Almshouse, or to the State Asylum 
for the Insane, there to be maintained at the expense of the State. The 
board may send to this asylum any insane pauper who has a legal settle- 
ment in any town, to be kept on such terms as may be agreed upon. The 
Agent of State Charities and Corrections shall visit all town asylums and 
all places where any insane person is kept, to see that no insane person 
is improperly confined or improperly cared for, and he may discharge at 
any time from any institution any insane person who has been committed 
thereto upon his order. No insane pauper shall be detained in any town 
asylum, poor-house, lockup, or bridewell for a longer period than five 
days, unless, in the opinion of the Agent of State Charities and Correc- 
tions, he is properly cared for. 

The Board of State Charities and Corrections may receive for treatment 
and care any person who shall be an inhabitant of the State who, in their 
opinion, is insane, upon such terms for treatment and care as may be 
agreed upon between said board and some responsible person, upon the 
written certificate of two practising physicians that, in their opinion, such 
person is insane. 



SOUTH CAROLmA.i 

The following persons shall be entitled to admission as patients to 
the State Hospital for the Insane : (1) All persons found to be idiots 
or lunatics by inquisition from the probate or circuit courts, or on trial 
in the circuit court. (2) Where the admission is requested by the 
husband or wife, or, where there is no husband or wife, by the next of kin 
of the idiot or lunatic. (3) All persons declared lunatics, idiots, or 
epileptics, after due examination by one trial justice and two licensed 

1 General Statutes of South Carolina, 1882, pp. 25, 270, 472-476, 751. The Code 
of Civil Procedure of South Carolina [bound with Gen. Stats.], pp. 15, 21, 22. 



APPENDIX — SOUTH CAROLINA. 519 

practising physicians of the State. In the case of a pauper, the ad- 
mission shall be at the request of the county commissioners of the 
county where the pauper has his legal settlement ; otherwise the admis- 
sion shall be at the request of the husband or wife or next of kin of the 
idiot, lunatic, or epileptic. 

Idiots and lunatics from other States may, when there is room in the 
asylum, be admitted on such evidence of their lunacy or idiocy as the 
regents regard sufficient, and they shall pay the same rates as citizen 
subjects. 

No lunatic, idiot, or epileptic, declared a fit subject for the asylum by 
a trial justice and two physicians, or sent from another State, shall 
be retained in the institution more than ten days, unless an order for his 
retention is made by the medical attendant and three, at least, of the 
regents of the asylum after a full examination of the patient's state of 
mind. Upon such order being made, the secretary of the board of 
regents shall make out certified copies of the papers in the case and send 
them to the judge of probate of the county where the patient resides, and 
said judge shall thereupon make such order in regard to the custody of 
the estate of the lunatic as would have been made had- the proceedings 
been under a writ de lunatico inquirendo. 

Whenever a judge of probate or a judge of the circuit court shall direct 
any trial justice to inquire as to the idiocy, lunacy, or epilepsy of any 
person, or when information on oath shall be given to any trial justice 
that a person is an idiot, lunatic, or epileptic, and is a pauper, such trial 
justice forthwith shall call to his assistance two licensed practising 
physicians and examine such person and hear the evidence in the case. 
If after full examination they find such person an idiot, lunatic, or 
epileptic, they shall certify either to the said judge or to the board of 
county commissioners whether, in their opinion, such person is curable or 
incurable, and whether or not he is dangerous to be at large, and thereupon 
the judge or the board of county commissioners, in his or its discretion, 
may order that the person be sent to the lunatic asylum. 

The judge of the probate court may commit to the lunatic asylum any 
idiot, lunatic, or person non compos mentis^ who, in his opinion, is so 
furiously mad as to be unfit to be at large. In all cases the judge shall 
certify in what place the said person resided. 

No patient shall be admitted to the asylum until the expenses of one- 
half year, or of such shorter time as the nature of the case seems to 
require, shall be paid in advance. A bond shall be given to secure the 
payment of all expenses ; but such bond shall not be required of the 
county commissioners sending a pauper patient to the institution. 

Whenever any lunatic or epileptic shall have recovered, it shall be the 
duty of the regents to discharge him from the asylum. Upon due notice 
from the superintendent of the asylum, the county commissioners of the 
various counties shall remove their imbeciles from the asylum, and shall 
take care of such persons in their respective county poor-liouses. 

It has been recently enacted that before any insane person not oftered 
as a pay patient is admitted to the asylum, the county commissioners 
shall investigate and see upon what footing the patient shall be admitted. 



520 APPENDIX — TENNESSEE. 

and whether or not he is able to pay some part of the expense of his 
support. 

In criminal cases, any judge of the circuit court is authorized to send 
to the lunatic asylum any person charged with the commission of any 
offence, who shall upon the trial before him prove to be non eompos 
mentis^ and the judge is authorized to make all necessary orders to carry 
into effect this power. 

No pauper lunatic, idiot, or epileptic, shall be confined for safe 
keeping in any jail ; and if any such person shall be imprisoned under, 
and by virtue of, any legal process, it shall be the duty of the sheriff, in 
whose custody he may be, to obtain his discharge as speedily as possible, 
and send him forthwith to the asylum, according to law. 

The county commissioners shall be authorized to send all pauper 
lunatics, idiots, and epileptics, in their several counties, to the lunatic 
asylum. 



TENNESSEE.^ 

Each county is entitled to send to the hospital its due proportion, both 
of private and pauper patients, according to its population and the number 
of its insane, but not more than one non-paying patient to each four 
thousand inhabitants. Each senatorial district is entitled to send four 
pauper patients at the expense of the State. 

No person shall be received as a private patient except by an order of 
the attending physician of the hospital, or at least two of the board of 
trustees. When the friends of such person supposed to be insane offer 
to place him in the hospital he shall not be admitted until the trustees 
have caused inquiry to be made as to the state of his mind, and have 
found him to be insane. A sworn certificate of insanity, in prescribed 
form, from at least one respectable physician, must be produced, setting 
forth that the patient is free from any infectious disease, and giving a 
concise history of the patient and his disease. 

For the commitment of State patients, some respectable citizen of the 
county where the patient belongs shall file with a justice of the peace a 
statement, setting forth that the person is insane, that his insanity is of 
less than two years' duration, or that he is dangerous to be at large, that 
he is in needy circumstances, has a legal settlement in the county, and 
is a citizen of Tennessee. It shall also give the names of two persons, 
one of them a physician, who can testify to the facts stated. The justice 
shall summon the witnesses named, and such others as he thinks proper. 
If, after inquest, the justice is satisfied of the truth of the statement, he 

1 Statutes of Tennessee, 1871, Thompson & Steger, Yol. I. pp. 767-781 ; Yol. II. 
pp. 1516-1521, 1700; Yol. III. p. 271, I 5488. Acts of Tennessee, 1873, pp. 74, 75, 
97; 1877, p. 71; 1883, p. 195. 



APPENDIX — TENNESSEE. 521 

shall require the medical witnesses to make a certificate, such as is required 
in the case of a pay patient, in regard to history, condition, etc. The 
justice shall also make a certificate, stating that he has examined the 
patient and finds him insane and poor, and a fit subject for the hospital. 
A certificate of the facts shall be filed by the justice with the clerk of 
the county court. The clerk shall send a copy to the superintendent of 
the hospital and make application for the patient's commitment. If the 
superintendent says that he can be received, the clerk shall issue a 
warrant directing that the patient be conveyed to the hospital. 

Both the county courts and the chancery courts have jurisdiction to 
order an inquisition to be made into the sanity of any person, and to 
appoint a guardian for his person and property, if he is found insane. 
If a person so found to be an idiot or lunatic has no property, or not 
sufficient for his maintenance, he may be let out for the term of one year 
to the lowest bidder as other poor persons, or otherwise provided for as 
the court may direct. Security is to be taken by the court for the proper 
treatment of such person. Any justice of the peace in the recess of 
court, if satisfied from the finding of a jury, or otherwise, that there is 
danger of violence by such idiot or lunatic, may commit him to jail until 
the next term of the court. 

When the plea of present insanity is urged in behalf of any person 
charged with a criminal oifence, punishable with imprisonment or death, 
and the jury find the defendant to be insane, and unsafe to be set at 
liberty, the court shall order the superintendent of the Hospital for the 
Insane to receive and keep the defendant as other lunatics are kept. 
When, in the opinion of the trustees and physician, such patient has re- 
covered from his insanity, they shall cause him to be delivered to the 
jailer of Davidson County for safe keeping, and shall send notice to the 
clerk of the county where the patient was arraigned. If, at the next 
term of the court, the district attorney wishes further to prosecute such 
person, he shall be taken to the county jail ; but, if the district attorney 
does not wish further to prosecute the prisoner, he shall be discharged. 

Whenever the physician of the penitentiary reports to the keeper that 
any convict is insane and ought, on chat account, to be removed to the 
lunatic asylum, the keeper shall cause such insane convict to be so re- 
moved, to remain in the hospital until discharged by the physician of the 
lunatic asylum. 

The trustees of the Hospital for the Insane have power to discharge 
at any time any of the patients in the hospital, unless committed to 
custody in the same by some court. 

No persons not citizens of the State shall be admitted as patients in 
the Hospital for the Insane. 



522 APPENDIX — TEXAS. 



TEXASJ 



The following persons may be admitted into the asylum as patients : 

1. All persons who have been adjudged insane by a court of competent 
jurisdiction in this State and ordered to be conveyed to the asylum. This 
class shall be known as public patients. 

2. All persons who may be certified to be insane by some respectable 
physician, under the regulations hereafter stated. This class shall be 
known as private patients. 

Before any person can be admitted as a private patient the parent or 
legal guardian of such person, or, in case he has no parent or legal 
guardian, some near relative or other person interested in him, must 
present a written request to the superintendent for his admission, setting 
forth the name, age, and residence of the lunatic, with such other par- 
ticulars as may be required. This request must be under oath and ac- 
companied with the affidavit of the physician certifying to the insanity 
that he has made careful examination of the person and verily believes 
him to be insane. There must also be a certificate from the county judge 
of the county where the lunatic resides, that the examining physician is 
a respectable physician in regular practice. 

All private patients shall be kept at their own expense, or the expense 
of their relatives or friends. 

All public patients shall be kept at the expense of the State, but money 
so paid may be collected from the patient or those liable for his support, 
if they have property. 

If applications be made for the admission of more patients than can be 
accommodated in the asylum, preference shall be given, in all instances, 
to public over private patients, and of the former class to cases of less 
than one year's duration over chronic cases, and to indigent patients over 
those possessed of property ; and no private patients shall be admitted 
during the pendency of an application by a public patient, nor shall any 
public non-indigent patient be admitted during the pendency of an appli- 
cation by an indigent public patient. 

No idiot who can be safely kept in the county to which he belongs, 
nor any person with an infectious or contagious disease, shall be received 
into the asylum as a patient. 

Any patient (except such as are charged with, or convicted of, some 
ofience and have been adjudged insane in accordance with the provisions 
of the Code of Criminal Procedure) may be discharged from the asylum 
at any time upon the recommendation of the superintendent, approved 
by the board of managers. Any patient coming within the above ex- 
ception can only be discharged by order of the court by which he was 
committed. 

No patient shall be discharged without suitable clothing, and money 

1 Revised Statutes of Texas, 1879, pp. 20-26, 386, 387. Penal Code [bound with 
Revised Statutes], p. 5. Code of Criminal Procedure [bound with Revised Statutes], 
pp. 66, 86, 112, 113. General Laws of Texas, 1883, pp. 9-11, 103-105. 



APPENDIX — TEXAS. 523 

sufficient to pay his expenses home. If discharged uncured, he shall be 
conveyed, under guard, to his friends, or to the county from which he 
was sent. 

If information in writing, under oath, be given to any county judge 
that any person in his county is a lunatic and ought to be placed under 
restraint, he shall, if he believes the statement, forthwith issue his warrant 
for the apprehension of such person, and shall fix a day for a hearing in 
the matter. He shall also have a jury of six competent persons of the 
county summoned to hear and determine the matter. The county 
attorney shall appear and represent the State, and the defendant shall be 
entitled to counsel, and in proper cases the court may appoint counsel 
for him. After the evidence is heard, the county judge shall submit the 
matter to the jury. Upon return of a verdict finding that the defendant 
is of usound mind, and that it is necessary that he be placed under 
restraint, judgment shall be entered adjudging him to be a lunatic and 
ordering him to be conveyed to the lunatic asylum for restraint and 
treatment. 

Immediately after any person is adjudged a lunatic tbe county judge 
shall communicate with the superintendent of the asylum, and, if notified 
that the patient can be accommodated, he shall issue his warrant to have 
the lunatic conveyed to the asylum without delay. No lunatic shall be 
taken to the asylum if some relative or friend will undertake, before the 
county judge, his care and restraint, giving a sufficient bond therefor. 

The proceedings in any inquisition of lunacy shall be entered of record 
in the county court, and a transcript made of the same and sent to the 
superintendent of the asylum when the patient is sent there. The county 
judge shall see that the patient is supplied with proper clothing before 
sending him to the asylum. 

No act done in a state of insanity can be punished as an offence. No 
person who becomes insane after he committed an offence shall be tried 
for the same while in such condition. No person who becomes insane 
after he is found guilty shall be punished for the offence while in such 
condition. 

Where the jury are of opinion that a person pleading guilty is insane, 
they shall so report to the court, and an issue as to that fact shall be 
tried before another jury. If upon such trial it be found that the de- 
fendant is insane, he shall be committed to the asylum in the same 
manner as where a defendant is found insane after conviction. 

If it be made known to the court at any time after conviction, or if 
the court has good reason to believe, that a defendant is insane, a jury 
shall be impanelled to try the issue. If the defendant has no counsel, 
the court shall appoint counsel for him. When a defendant is found by 
the jury to be insane, the court shall make an order committing the de- 
fendant to the custody of the sherifif. The proceedings shall then forth- 
with be certified to the county judge, who shall take the necessary steps 
at once to have the defendant confined in the lunatic asylum until he 
becomes sane. Should the defendant become sane, he shall be brought 
before the court in which he was convicted, and a jury shall again'be 
impanelled to try the issue of his sanity ; and should he be fouiui to be 
sane, the conviction shall be enforced asainst him in the same manner as 



524 APPENDIX — UTAH. 

if the proceedings had never been suspended; if found insane, he shall be 
remanded to the lunatic asylum. 

The judge of the county court may, on proper information and pro- 
ceedings, appoint a guardian for any person of unsound mind. 

If any person shall be furiously mad or so far disordered in his mind as 
to endanger his own person or the property of others, it shall be the duty 
of the guardian or other person, under whose care he may be, to confine 
him in some suitable place until the first regular term of the county 
court of his county, when the court shall make such order for the restraint, 
support, and safe keeping of such person as the circumstances may re- 
quire. If the persons having charge of such an insane person do not 
confine him, or if there be no one in charge of hirp, any magistrate may 
cause him to be apprehended, and may employ any person to confine him 
in some suitable place until the county court makes further order in regard 
to him. 



UTAH.^ (Territory.) 

Patients may be admitted to the asylum in the following manner : The 
probate judge of any county shall, upon application, under oath, setting 
forth that a person, by reason of insanity, is dangerous to be at large, 
cause such person to be brought before him, and shall summon to appear 
at the same time two or more witnesses who well knew the person alleged 
to be insane, who shall testify as to his conversation, manners, and gen- 
eral conduct ; and the judge shall also cause to appear, at the same time, 
two practising physicians, who shall be present during the hearing. If, 
after a hearing of the evidence, and a personal examination of the alleged 
insane person, the physicians shall certify that the person is insane, and 
the case is of a recent or curable character, or that the insane person is 
of a homicidal, suicidal, or incendiary disposition, or that from any other 
violent symptoms he would be dangerous to be at large, the judge, if con- 
vinced that the facts are in accordance with the physicians' certificate, 
shall direct the sherifi" or some suitable person to convey to, and place in 
charge of the officers of, the Territorial Insane Asylum such insane 
person. The physicians shall also certify to the name, age, nativity, resi- 
dence, occupation, length of time in the Territory, State or country last 
lived in, previous habits, premonitory symptoms, apparent cause and class 
of insanity, duration of the disease and present condition, as nearly as 
may be ascertained by examination and inquiry. A copy of the com- 
plaint, commitment, and physicians' certificate shall be sent to the medi- 
cal superintendent of the asylum. 

No case of idiocy, imbecility, harmless chronic mental unsoundness or 
delirium tremens shall be committed to the asylum. If any persons of 

1 Laws of IJtali, 1878, pp. 134, 135, 159-161 ; 1880, pp. 57-65, 75; 1882, p. 82. 



APPENDIX — UTAH. 525 

either of these classes are unlawfully placed in the asylum, the superin- 
tendent may discharge them and return them to the county from which 
they were committed. 

If an insane person committed to the asylum has property, the judge 
shall appoint a guardian to take charge of the same, and apply it to 
pa3'ing the expenses of the insane person in the asylum. 

The kindred or friends of an inmate of the asylum may receive 
such inmate therefrom, upon giving satisfactory evidence that they are 
capable and suited to take charge of, and give proper care to, such insane 
person, and exercise proper restraint over him. If the evidence satisfies 
the judge on these points, he may make an order, directed to the medical 
superintendent of the asylum, for the removal of such person. If, after 
such removal, the insane person is not properly cared for or restrained, 
the judge may order him to be returned to the asylum. 

Non-residents of the Territory shall not be committed to, nor supported 
in, the asylum, except temporarily, until they can be returned to their 
home or friends. 

Indigent patients shall be supported in the asylum by the county from 
which they are sent. 

A person cannot be tried, adjudged to punishment, or punished for a 
public offence while he is insane. When an indictment is called for trial, 
if a doubt arises as to the sanity of the defendant, the court must order 
the question to be submitted to a jury ; when such doubt arises on the 
defendant being brought up for judgment on conviction, the court must 
order a jury to be summoned from the list of jurors provided by law to 
inquire into the fact, and the trial of the indictment, or the pronouncing 
of the judgment, must be suspended until the question of insanity is 
determined by the verdict of the jury. If the jury find the defendant 
insane, the trial or judgment must be suspended until he becomes sane, 
and the court, if it deems his discharge dangerous to the public peace or 
safety, may order that he be in the mean time committed by the proper 
officer to a lunatic asylum. If the defendant is received into an asylum, 
he must be detained there until he becomes sane, when he must be brought 
from the asylum and placed in proper custody until he is brought to trial 
or judgment, as the case may be, or is legally discharged. 

If, after judgment of death, there is good reason to suppose that the 
defendant has become insane, the proper officer, with the concurrence of 
the judge of the court by which the judgment was rendered, may sum- 
mon from the list of jurors selected by the proper ofiicers for the year a 
jury of twelve persons to inquire into the supposed insanity. The prose- 
cuting attorney must attend the inquisition, and may produce witnesses. 
If it is found by the inquisition that the defendant is insane, the officer 
must suspend the execution of the judgment until he receives a warrant 
from the Governor, or from the judge of the court by Avhich the judg- 
ment was rendered, directing the execution. The Governor, when the 
defendant becomes sane, may appoint a day for the execution of the 
judgment. 



626 APPENDIX — VERMONT. 



VERMONT.^ 

No person shall be admitted to, or detained in, an insane asylum as a 
patient or inmate, except upon the certificate of such person's insanity, 
stating the reasons for adjudging such person insane, made by two 
physicians of unquestioned integrity and skill, residing in the probate 
district in which such insane person resides, or, if such insane person is 
not a resident of the State, in the probate district in which the asylum 
is situated ; or if such insane person is a convict in the State Prison or 
House of Correction, such physicians may be residents of the probate 
district in which such place of confinement is situated. The two 
physicians making such certificate shall not be members of the same 
firm and neither shall be an officer of an insane asylum of this State. 

The next friend or relative of a person thus found insane, may appeal 
to the supervisors of the insane. The supervisors shall examine the case, 
the examination being had in the town where the appellant resides. 
Pending the appeal, the patient shall not be committed to the asylum. 
If the supervisors find that there was not sufficient ground for making 
the certificate, they shall declare it void. 

Idiots and persons non compos, who are not dangerous, shall not 
be confined in an asylum for the insane, and, if any such persons are so 
confined, the supervisors of the insane shall cause them to be discharged. 

The physicians' certificate, above mentioned, shall be made not more 
than ten days previous to the admission of such insane person to the 
asylum and not more than five days after making a careful examination. 
There must be a certificate of the judge of probate of the district in 
which the physicians reside, that the physicians are of unquestioned 
integrity and skill in their profession. This certificate shall be presented 
to the proper officer of the asylum at the time the patient is presented for 
admission. 

Any physician signing a certificate without first making a careful exami- 
nation of the supposed insane person, shall be liable to a penalty of from 
$50 to $100, in case the person is sent to an asylum on such certificate. 

A person may be received into an asylum without a certificate, by the 
order or sentence of the supreme or county court, upon the presentation 
of a certified copy of the order or sentence. 

If the probate judge, in a case duly brought before him by the select- 
men of a town and the State's attorney, finds that an insane person is 
without a settlement in any town and is liable to be supported by the 
State, and the insanity of such person is certified to by two physicians of 
unquestioned skill and integrity, resident in said probate district, who are 
duly indorsed by said judge, the judge shall issue an order for the 
removal of such insane person to the Vermont Asylum for the Insane, to 
be there supported. The officer, or other person appointed by the judge 
to transport such insane person to the asylum, shall leave with the super- 

1 Revised Laws of Vermont, 1880, pp. 355, 491, 559-565, 843, 844. Laws of Ver- 
mont, 1882, pp. 55-59. 



APPENDIX — VERMONT. 527 

intendent, or one of the trustees of the asylum, a copy of the judge's 
order and also a copy of the physicians' certificate indorsed by the judge. 
When such person is lawfully discharged from the asylum, the town 
causing him to be removed thereto shall take charge of and support him 
again. 

No patient shall be supported in the asylum entirely at the expense of 
the State unless he is sent there upon the order of a probate judge, or 
from the State Prison or House of Correction, or upon the order or sen- 
tence of the county or supreme court. Insane town paupers or insane 
persons in indigent circumstances shall be supported by the town where 
they belong, at the Vermont Asylum for the Insane. The selectmen 
may make contracts with the officers of the asylum for their support. If 
a person is insane and his property is not sufficient to support himself 
and his wife and children, his wife may complain to the county court in 
the county where such insane person has his settlement, and the court, 
after a hearing, may order the town to support the insane person at the 
asylum. In certain cases the State will pay a part of the expenses 
of poor patients placed in the hospital by the selectmen of a town. 

There shall be three supervisors of the insane elected by the general 
assembly, two of whom shall be phj^sicians, and none of them shall be a 
trustee or officer of an insane asylum in the State. The supervisors 
shall visit every asylum for the insane in the State, one of the board as 
often as once a month, and they shall examine into the management 
and condition of the patients, and they shall particularly ascertain 
whether persons are confined in any asylum who ought to be discharged, 
and they may make such orders as any case requires. The supervisors 
may discharge, by their order in writing, any person confined as a patient 
in any asylum for the insane whom they find, on investigation, to be 
wrongfully confined, or whom they find so far sane as to warrant dis- 
charge. But convicts sent to the asylum from the State Prison or 
House of Correction, w^ho are found insane before the expiration of their 
sentence, shall not be discharged, but shall be returned to the prison or 
house of correction. In no case shall the supervisors order the discharge 
of a patient without giving^ the superintendent of the asylum an 
opportunity to be heard. 

The Governor may refer the case of any patient in the asylums for the 
insane to the supervisors for their investigation. If in any case they 
have not the power to grant the necessary relief, they shall, if the patient 
is one of the insane poor of the State, cause such proceedings to be com- 
menced in court as are necessary to obtain the required relief. 

The friends or relatives of a patient may apply to the supervisors 
to inquire into the treatment and confinement of such patient, and the 
supervisors shall take such action upon such application as it requires. 

If a trustee, superintendent, employe, or other officer of an asylum 
for the insane wilfully and knowingly neglects or refuses to discharge a 
patient after such patient has become sane, or after the supervisors have 
ordered his discharge, he shall be fined not more than JoOO. 

It shall be the duty of the legal guardian of any insane person not a 
pauper, and the duty of the overseer of the poor of the town in which 
any insane person who is a pauper resides, when such insane person 



528 APPENDIX — VERMONT. 

is not placed in an asylum, to keep such insane person under such 
restraint as may be necessary to prevent his going at large. If any 
insane person, not a pauper, found going at large in any town, shall have 
no legally appointed guardian, application for the appointment of a 
guardian over him may be made to the probate court of the district in 
which such insane person resides by the selectmen of the town where 
such insane person is going at large. 

When a person held in prison on a charge of having committed an 
oifence is not indicted by the grand jury by reason of insanity, the grand 
jury shall so certify to the court, and thereupon if the discharge or going 
at large of such insane person is deemed manifestly dangerous to the 
community, the court may order him confined in the county jail or in 
the insane asylum at Brattleboro or some other suitable place at his 
ow^n expense if he has estate sufficient for the purpose, and, if not, at the 
expense of the State. 

When a person tried on an indictment or information for any crime or 
offence is acquitted by the jury by reason of insanity, the jury, in giving 
their verdict of not guilty, shall state that it is given for such cause, and 
thereupon, if the discharge or going at large of such insane person 
is considered dangerous, the court may order him, in its discretion, to be 
confined in the State Prison or in the insane asylum at Brattleboro, on 
such terms as the court directs. 

A person confined as insane under an order of court, after having been 
acquitted or not indicted because of his insanit}^, shall be discharged 
from confinement only by order of the county court for the county 
in which the order for confinement was made, upon petition therefor, and 
after notice to the State's attorney. 

In case such person is confined in the insane asylum at Brattleboro, 
and has no estate, such petition may be brought in his behalf by the 
supervisors of the insane at the expense of the State. The court thus 
petitioned may direct that such insane person be brought before it for 
hearing. If, upon hearing, it appears to the court that such person has 
become sane, and his discharge or going at large is not considered by the 
court dangerous to the community, the court shall order the discharge of 
such person from confinement. Otherwise the petition shall be dismissed 
and such person shall be recommitted to the place of confinement from 
which he was brought. 

When a person acquitted of any crime or offence because of his 
insanity is confined by order of the court, such court may, on petition 
and after notice to the State's attorney, alter the terms on which such 
person is confined. 

When a person confined in the house of correction or State Prison for 
a specified time, or for life, becomes insane, and proper certificates of that 
fact are made, the directors may cause such prisoner to be removed to the 
insane asylum at Brattleboro, on such terms as they deem just, there to 
remain until he becomes cured of his insanity, or until the expiration of 
the term for which he was committed to the prison or house of correction. 

If before the expiration of such term such person becomes sane, he 
shall be returned to the institution to which he was originally committed, 
and confined therein for the remainder of said term. A prisoner, who at 



APPENDIX — VIRGINIA. 529 

the expiration of his term of confinement remains insane, may be removed 
to the insane asylum at Brattleboro, and may be there kept, or, if already 
there, may remain at the expense of the State or of the town where 
he belongs, or of the relatives bound to support him. 



VIRGINIA.^ 



On an application on behalf of a person for his admission into an 
asylum, the examining board (directors of the asylum), if unanimous 
that he ought to be admitted, may receive him as a patient therein, pro- 
vided sufficient security is given for the payment of the patient's ex- 
penses, and his removal when required. 

Any justice who shall suspect any person in his county or corporation 
to be a lunatic shall have such person brought before him. He and two 
other justices shall inquire whether such person be a lunatic, and, for 
that purpose, summon his physician, if any, and any other witnesses. 
They shall, so far as the same are applicable, propound sixteen prescribed 
questions relating to the history and condition of the patient. If the 
said justices decide that the person is a lunatic, and ought to be confined, 
and ascertain that he is a citizen of the State, then, unless some person 
will give bond, with sufiicient security, to restrain and take proper care 
of such lunatic, the justices shall order him to be taken to the nearest 
asylum, if there be room therein, and, if not, to the other. The written 
interrogatories and answers, and a written statement by the justices as to 
the fact of insanity, shall be sent with their order to the asylum. The 
sheriff or officer who is to execute the order of the justices shall ascertain 
whether there is a vacancy in the nearest asylum, and, if there be none, 
he shall make inquiry of the other superintendents. Until it is ascer- 
tained that there is a vacancy, the patient shall be kept in the jail of 
the county or corporation. When such patient arrives at the asylum, the 
board of directors shall be assembled, as soon as may be, and, if they 
concur in opinion with the justices, they shall receive and register him as 
a patient. If they refuse to receive the lunatic, the officer in whose cus- 
tody he may be shall confine him in the jail of the county where he was 
examined until lawfully discharged or removed therefrom. If a person 
found insane is not sent to an asylum, he shall be placed in the hands of 
a committee of the person and estate. 

If a lunatic who is committed to jail, or received into an asylum, is 
found to be a non-resident of the State, he shall, as soon as practicable, 
be returned to his friends or to the proper authorities of the State where 

1 Code of Virginia, 1873, pp. 714-725, 1241, 1247, 1248. Acts of Assembly, Vir- 
ginia, 1874, pp. 23, 24; 1875-76, p. 8; 1876-77, pp. 38, 39; 1877-78, pp. 215, 216; 
1878-79, pp. 367, 368; 1881-82, pp. 134, 135. 

84 



530 APPENDIX — VIRGINIA. 

he belongs. No non-resident lunatic shall be admitted or retained In 
either asylum as a pay patient, except when there is a vacancy not applied 
for on behalf of any person residing in the State. 

The Governor is authorized to cause insane persons not now kept in 
either of the State lunatic asylums to be taken to and kept in such insane 
asylums beyond the limits of the State as he may select, and he may make 
all necessary arrangements with the persons having charge of such asylums. 

Insane persons of the naval service of the United States who may be 
sent to either asylum by the Secretary of the Navy may be received so 
long as there is room in the asylums, but when it shall become necessary 
for the purpose of accommodating insane persons who are citizens of the 
State, such insane persons of the naval service, or so many as may be 
necessary, shall be removed from the asylums and restored to the care of 
the Secretary of the Navy. 

Idiots may not be sent to, or kept in, the insane asylums, but shall be 
taken charge of by their committees or by the overseers of the poor= 

Except in the case of patients charged with crime, the board of any 
asylum, or the court of any county or corporation, may deliver any lunatic 
confined in such asylum, or in the jail of the county, to any friend who 
will give proper bond to take care of him, and where any lunatic not a 
criminal is deemed by the superintendent of any asylum both harmless 
and incurable, the board may deliver him, without any bond, to any 
friend who is willing and able to take care of him. 

If any person who has given bond and taken charge of a lunatic Welshes 
to be relieved of the care of him, he may deliver him to the sheriff of the 
county, or sergeant of the corporation, according to the condition of the 
bond. Such sheriff or sergeant shall carry the lunatic before a justice of 
his county or corporation, and the regular proceedings shall be had for 
committing the patient to an asylum. 

If a person who has given bond to take care of a lunatic desires to put 
him in an asylum, he may take the patient directly before a justice, and 
may perform all the duties that a sheriff or sergeant might perform in 
the matter of having him committed to the asylum. 

When a person in jail on a charge of having committed a criminal 
offence appears, from a certificate of a grand jury, or otherwise, to the 
satisfaction of the court in which he is held to answer, to have been 
insane at the time of committing the act, and continues to be so insane, 
the court, in its discretion, may order him to be sent to one of the lunatic 
asylums of the State, or to be delivered to his friends. 

If a court in which a person is held for trial see reasonable ground to 
doubt his sanity at the time of trial, it shall suspend the trial and impanel 
a jury to inquire into the insanity. If the jury find that the accused is 
insane, they shall inquire whether or not he was so at the time of the 
alleged offence. If they find that he was insane at that time, the court 
may dismiss the prosecution, and either discharge him or, to prevent his 
doing mischief, remand him to jail and order him to be removed thence 
to one of the lunatic asylums. If they find that he was not insane at the 
time the offence was committed, but has become so since, the court shall 
commit him to jail or order him to be confined in one of the asylums 
until he is so restored that he can be put on trial. 



) 



APPENDIX — WASHINGTON. 531 

When a person tried for an offence is acquitted by the jury by reason 
of his being insane, the verdict shall state the fact, and thereupon the 
court may, if it deems him dangerous, order him to be committed to jail 
until he can be sent to one of the asylums. 

If, after conviction and before sentence of any person, the court see 
reasonable ground to doubt his sanity, it may impanel a jury to inquire 
into the fact as to his sanity, and sentence him or commit him to jail or 
to a lunatic asylum, according as the jury may find him to be insane or 
sane. 

When any person confined in an asylum and charged with crime, and 
subject to be tried therefor, or convicted of crime, shall be restored to 
sanity, the board shall give notice thereof to the clerk of the court by 
whose order, or by the order of the judge of which he was confined. 
Such clerk shall issue a precept requiring the prisoner to be brought 
from the asylum and committed to jail. When a prisoner is so brought 
from the asylum and committed to jail, or when it is found by the verdict 
of another jury that a prisoner whose trial or sentence was suspended by 
reason of his being found to be insane has been restored to reason, if he 
has already been convicted, he shall be sentenced ; if not, the trial shall 
be held as if no delay had occurred on account of his insanity. 

When any person not a criminal, confined in an asylum or jail as a 
lunatic, shall be restored to sanity, the board or the court, as the case may 
be, shall discharge him and give him a certificate thereof. 

When any person shall be confined in any jail as a lunatic, the jailer 
shall certify the fact to the court of the county or corporation at their 
next term. The court shall thereupon cause such person to be examined 
by two disinterested persons, who shall, as soon as may be, report the 
result thereof The court shall then make such provision for the main- 
tenance and care of the patient as his condition may require. It shall, 
when practicable and proper, contract with some fit person for the main- 
tenance and care of such lunatic out of the jail, and make allowance for 
the expense of such support not exceeding what is authorized for a lunatic 
confined in jail. 

The committee of an insane person appointed by the circuit or county 
courts shall be entitled to the custody and control of his person when he 
resides in the State and is not confined in an asylum or jail. 



WASHINGTON.^ (Territory.) 

No person laboring under any contagious or infectious disease shall be 
admitted to the lunatic hospital as patient. In admitting patients to, and 
retaining them in, the hospital, the indigent insane of the Territory shall 

1 Washington Code and Appendix, 1881, pp. 203, *204, 276-281, 351, 388-394. 



532 APPENDIX — WASHINGTON. 

have precedence, and if the hospital at any time becomes crowded, recent 
cases shall, for the time being, have precedence over those of a chronic 
character. 

The probate court of any county, or the judge thereof, upon applica- 
tion of any person, under oath, setting forth that any person, by reason 
of insanity, is unsafe to be at large, or is suffering under mental derange- 
ment, shall cause such person to be brought before said court, or judge, 
at a time appointed, and shall cause to appear at the same time one or 
more respectable physicians, who shall state, under oath, in writing, their 
opinion of the case. If the physician or physicians shall certify to the 
insanity or idiocy of the person, and it appears to the satisfaction of the 
court, or judge, that such certificate is true, said court, or judge, shall 
cause such insane or idiotic person to be taken to the Hospital for the 
Insane in Washington Territory ; provided, that such alleged insane per- 
son, or any person in his behalf, may demand a jury to decide upon the 
question of his insanity, and the court, or judge, shall discharge such 
person if the verdict of the jury is that he is sane. 

The probate court, or judge, shall also inquire as to the property of 
such insane person, and in case such person shall have sufficient means 
to bear such expense, two months' charges shall be paid in advance on 
his admission, and a like amount every two months thereafter so long as 
he remains in the hospital. If the relations or friends of such insane or 
idiotic person desire to take charge of him, the court, or judge, may so 
order, if sufficient bond is given that such insane or idiotic person shall 
be well and securely kept. If it be found by the court that the person 
so brought before it is of unsound mind, and incapable of managing his 
own affairs, and has property, the court shall appoint a guardian for the 
estate of such insane person. 

Paying patients, whose friends or whose property can pay their ex- 
penses, shall do so in accordance with the contract made with the trustees 
of the hospital. 

Whenever the court shall receive information that an insane person 
under guardianship has recovered his reason, it shall inquire into the 
facts, and, if it finds that such person is of sound mind, shall forthwith 
discharge him from care and custody. 

Any patient may be discharged from the hospital, when, in the judg- 
ment of the superintendent, it may be expedient. 

Whenever a patient not cured, or any indigent patient, shall be ordered 
discharged, he shall, if the superintendent thinks fit, be sent unattended 
to the county where he belongs ; but if for any reason he is unfit to be 
sent alone, the superintendent shall so certify to the probate judge of said 
county, who shall order the sheriff to remove the patient to the county 
from w^hich he came. No pauper shall be discharged from the hospital 
without suitable clothing, and such sum of money, not exceeding $10, 
as the trustees deem necessary. 

There shall be no censorship exercised over the correspondence of the 
inmates of insane asylums, except as to the letters to them directed ; but 
their other post-office rights shall be as free and unrestrained as are those 
of any other resident or citizen of this Territory, and be under the pro- 
tection of the same postal laws ; and every inmate shall be allowed to 



APPENDIX — WEST VIRGINIA. 633 

write one letter a week to any person he or she may choose. There shall 
be a post-office box in the asylum. 

In all asylum investigations, the testimony of any person offered as a 
witness, whether sane or insane, shall be competent, the court and jury 
being sole judges of its credibility. 

The district courts of the Territory shall have power to commit to the 
insane hospital any person who, having been arraigned for an indictable 
offence, shall be found by the jury to be insane at the time of such 
arraignment. 

When any person indicted for an offence shall on trial be acquitted by 
reason of insanity, the jury, in giving their verdict, shall so state, and 
thereupon, if the discharge or going at large of such insane person shall 
be considered by the court manifestly dangerous, the court may order 
him to be committed to the insane asylum, or may give him into the care 
of his friends, if they will give sufficient bonds that he will be well and 
securely kept. Otherwise he shall be discharged. 



WEST YIRGINIA.i 

Any justice who shall suspect any person in his county to be a lunatic, 
shall issue his warrant and have the person brought before him. He shall 
make inquiry whether such person is a lunatic, and for that purpose sum- 
mon a physician and other witnesses. He shall propound so many of 
fifteen prescribed questions as are applicable to the case, touching the 
history and condition of the patient. If the justice decide that the per- 
son is a lunatic and ought to be confined in the hospital, and ascertain 
that he is a citizen of the State, then, unless some person will give suffi- 
cient security to restrain and take proper care of such lunatic, the justice 
shall order him to be removed to the hospital. The interrogatories and 
their answers, together with a written statement by the justice of any 
facts relating to the insanity, shall be sent with the order to the hospital. 
The sheriff or other officer who is to execute the order, shall make 
inquiry of the superintendent whether he can receive the lunatic into the 
hospital, and whether he will send for the patient or have the sheriff take 
him to the hospital. Until the patient can be received in the hospital, 
he shall be kept in the jail of the county. When sucli patient arrives at 
the hospital, the examining board, consisting of the medical superinten- 
dent and one or more directors, shall be assembled as soon as may be, 
and, if they concur in opinion with the justice, the patient shall be 
registered as an inmate upon proper security for payment of expenses. 
If they refuse to receive the lunatic, the officer in charge of him shall 

1 Eevised Statutes of West Yiro-inia, Annotated, 1879, Vol. I. pp. 440, 440. 447; 
Vol. II. pp. 673-680 Acts of West Virginia, 1881, p. 266; 1882, pp. 133-137; 
1883, pp. 55, 56. 



534 APPENDIX — WEST VIRGINIA. 

confine him in the jail of the county in which he was examined until 
lawfully discharged or removed therefrom. 

If a lunatic is found to be a non-resident, he shall be returned to his 
friends or to the proper authorities of the State from which he came, and 
the Governor shall collect from that State, if possible, the money expended 
for such patient. 

No non-resident lunatic shall be received or retained as a pay pa^tient 
in the hospital, except when there is a vacancy not applied for on behalf 
of any person residing in the State. 

Insane persons of the naval service of the United States, who may be 
sent to the hospital by the Secretary of the Navy, may be received and 
kept so long as there is room not wanted for citizens of the State. 

Idiots are not to be sent to or received into the hospital, but are to be 
taken charge of by their committees if they have any, if not, by the 
supervisors or any of them. 

Except in case of insane criminals, the board of the hospital, or the 
circuit court of any county, may deliver any lunatic confined in the hos- 
pital, or in the jail, to any friend who will give sufiicient security to 
restrain and properly care for the lunatic; and where a lunatic, not a 
criminal, is deemed by the superintendent of the hospital both harmless 
and incurable, the board may deliver him without any bond to any friend 
who is willing, and, in the opinion of the board, able to take care of him. 

When any person who has given bond and taken charge of a lunatic 
wishes to be relieved of the care of him, he may deliver him to the 
sheriff of the county according to the condition of the bond. The sherifi" 
shall confine such patient in the jail of his county until a vacancy shall 
occur in the hospital. 

When any person shall be confined in any jail as a lunatic, the jailer 
shall certify the fact to the circuit court of the county at the next term. 
The court shall cause such person to be examined by two disinterested 
persons, who shall, as soon as may be, report the result thereof. The 
court shall then make such provision for his maintenance and care as his 
situation may require. The court in whose jail any lunatic may be con- 
fined, shall, when practicable and proper, contract with some fit person 
for the care and maintenance of such lunatic out of jail, and make allow- 
ance therefor not exceeding what is authorized for a lunatic confined 
in jail. 

The circuit court shall, on application of any party interested, examine 
any person suspected of being insane, with a view to appointing a com- 
mittee. If a person be found to be insane by the justice before whom 
he may be examined, or in a court in which he may be charged with 
crime, the circuit court of the county of which he is an inhabitant shall 
appoint a committee of him. The committee of an insane person 
shall be entitled to the custody and control of his person when he resides 
in the State and is not confined in the hospital or jail. 

When any person, not a criminal, confined in the hospital or jail as a 
lunatic shall be restored to sanity, the board of directors, if such person 
be in the asylum, or, if confined in jail, the circuit or county court, or 
any justice of the county in which such person is confined, upon exami- 



APPENDIX — WISCONSIN. 635 

nation of such person, if it be found proper to do so, shall discharge 
such person and give him a certificate thereof. 

When a person in jail, on a charge of having committed an indictable 
offence, is not indicted by reason of his insanity at the time of commit- 
ting the act and the grand jury certify this fact, the court may order him 
to be sent to the hospital for the insane of the State, or to be discharged. 

If a court in which a person is indicted for a criminal offence see reason- 
able ground to doubt his sanity, at the time of trial, it shall suspend the 
trial and impanel a jury to inquire into the insanity. If the jury find 
that he is then insane, they shall inquire further whether he was so at 
the time of the alleged offence. If they find that he was so at that time, 
the court may dismiss the prosecution and either discharge him or, to 
prevent his doing mischief, remand him to jail and order him to be 
removed thence to the hospital for the insane. If they find that he was 
not insane at the time of the alleged offence, but has since become so, 
the court shall commit him to jail, or order him to' be confined in the 
hospital until he is so restored that he can be put upon his trial. 

When a person tried for an offence is acquitted by the jury by reason 
of his being insane, the verdict shall state the fact, and thereupon the 
court may, if it deem him dangerous, order him to be committed to jail 
until he can be sent to the hospital for the insane. 

If, after conviction and before sentence of any person, the court see 
reasonable ground to doubt his sanity, it may impanel a jury to inquire 
into the fact as to his sanity, and sentence him or commit him to jail or 
to the hospital for the insane, according as the jury may find him to be 
sane or insane. 

When any person confined in the hospital and subject to be tried for 
crime, or convicted of crime and held for sentence, shall be restored 
to sanity, the board shall give notice thereof to the clerk of the court by 
whose order he was confined. Such clerk shall issue a precept requiring 
the prisoner to be brought from the hospital and committed to jail. When 
a prisoner is so brought to the jail, or when it is found^ by the verdict of 
another jury that a prisoner whose trial or sentence was suspended 
by reason of his being found to be insane, has been restored, if already 
convicted, he shall be sentenced, and, if not, the court shall proceed to 
try him as if no delay had occurred on account of his insanity. 



WISCONSIN.^ 



The management of the insane asylums is in the hands of the State 
board of supervision of Wisconsin charitable, reformatory, and penal in- 

1 Ilevised Statutes of Wisconsin, 1878, pp 60, '205-215, 402, 520, 661, 662, 97o- 
975, 1012, 1098, 1099, 1189, 1140. Laws of Wiso^nisin, 1880. pp. 121. 122, 299-302, 
317; 1881, pp. 245, 246, 274, 275, 283-287, 376, 378-388; 1882. pp. 400, 914; 1883, 
Yol. I. pp. 24-28, 128. 129, 135-138. 



536 APPENDIX — WISCONSIN. 

stitutions, which acts as commissioners of lunacy, with power to investi- 
gate the question of the insanity and condition of any person committed 
or confined in any lunatic hospital or asylum, public or private, or re- 
strained of his liberty by reason of alleged insanity. The board shall 
take the proper legal steps for the discharge of any person so committed 
or restrained, if, in its opinion, such person is not insane, or can be cared 
for after such discharge without danger to others and with benefit to 
himself. Any letter, communication or complaint, addressed to such 
board, or to any member thereof, by any inmate or employe in any of 
said institutions, shall be forwarded as addressed, without being opened 
or interfered with. 

Patients shall be admitted to the hospitals for the insane from the 
several counties in the ratio of their population, but each county shall 
be entitled to at least two patients, if desired. 'No person idiotic from 
birth shall be admitted ; and no person shall be retained in either hospital 
after, by a fair trial, it shall have become reasonably certain that such 
person is incurably insane, if the room is wanted for cases of a more 
hopeful character. But no person in the hospitals committed as an 
insane criminal shall be discharged without an order of the court having 
jurisdiction over such person. 

Whenever any resident of this State, or any person found therein 
whose residence cannot be ascertained, shall be, or be supposed to be, 
insane, application may be made in his behalf by any respectable citizen 
to the judge of the county court, judge of the circuit court, or any judge 
of a court of record in and for the county in which the patient resides, 
or, in case his residence is unknown, the county in which he is found, 
for a judicial inquiry as to his mental condition, and for an order of com- 
mitment to some hospital or asylum for the insane. 

The application shall be in wTiting, and shall specify whether or not 
a trial by jury is desired by the applicant. The judge applied to shall 
appoint two disinterested physicians of good repute for medical skill and 
moral integrity to visit and examine the person alleged to be insane. 
Such physicians shall forthwith, by personal examination, satisfy them- 
selves as to the patient's condition and report to the judge. Such report 
shall cover twenty-nine prescribed points touching the history and con- 
dition of the patient. Upon the receipt of the physicians' report the 
judge may, if no demand has been made for a jury, make his order of 
commitment to the hospital or asylum of the district to which the county 
belongs, or, if not fully satisfied, may make further investigation of the 
case. At any stage of the proceedings, and before the actual confinement 
of the person, he, or any relative or friend acting in his behalf, shall have 
the right to demand that the question of sanity be tried by a jury. In 
case a trial by jury is demanded, the forms of procedure shall be the 
same as in trials by jury in justices' courts, and the trial shall be in the 
presence of the person supposed to be insane, and his counsel and imme- 
diate friends, and the medical witnesses. All other persons shall be ex- 
cluded. If the jury find the person sane, he shall be discharged. If 
they find him insane, and a fit person to be sent to a hospital for the 
insane, they shall so state. 

The physician's report or certificate shall be sent with the patient to 



APPENDIX — WISCONSIN. 537 

the hospital or asylum. All proceedings relating to the commitment of 
insane persons shall be filed with the county judge of the county in which 
the insane person resides, who is required to keep a record-book, in which 
all proceedings shall be recorded, and be open to inspection. Whenever, 
in the opinion of the judge applied to, the public safety requires it, he 
may order the sheriff forthwith to take and confine the supposed insane 
person in some place specified, until the further proceedings for his com- 
mitment can be had, or until the further order of the judge. Or if, after 
the receipt by the judge of the report of the examining physician, he 
deems it proper, he may order the sheriff then to take the alleged insane 
person into custody, and keep him in some place specified until the 
further order of the judge. 

When any respectable citizen has reason to question the propriety or 
justice of the confinement of any patient committed to any hospital or 
asylum, he may apply to any of the judges above mentioned of the county 
in which such person resides, asking for a rehearing 'and a further judi- 
cial inquiry as to the mental condition of such person. The proceedings, 
upon the rehearing, shall be substantially the same as upon the original 
commitment. If, upon such rehearing, the patient is found to be sane, 
an order shall be made that he be set at liberty. If it is determined that 
he is insane, no further action shall be taken upon the application. 

]^o person not deemed dangerous when at large shall be committed to 
any hospital or asylum for the insane solely on account of physical in- 
firmity or mental imbecility. 

If any relative or friend of a patient committed to any hospital desires 
to perform the duty of taking him to the hospital, and is competent to do 
so, the warrant of commitment may be delivered to and executed by him, 
instead of by the sheriff. 

Each patient sent to the hospital must be furnished with the amount 
of clothing prescribed, or he may be rejected by the superintendent. 

When a patient is discharged as cured, the superintendent shall furnish 
him with suitable clothing, and a sum of money not exceeding $20. 

If the relatives or friends of any patient shall ask the discharge of 
such patient before he has recovered from his insanity, the superintendent 
may, in his discretion, require a bond to be executed, conditioned for the 
safe keeping of such patient. 

Incurable and harmless patients shall be discharged whenever it is 
necessary to make room for recent or more hopeful cases, except in case 
of persons under the charge of, or conviction of, crime. 

When an order is made for the removal of a patient, the superinten- 
dent, except when friends are willing to receive the patient, shall notify 
the county judge of the county from which the patient was sent, and he 
shall issue his warrant, directing the sheriff to remove the patient to the 
poor-house or jail in the county whence he was taken. Patients in either 
of the hospitals found to be non-residents of the State shall, when prac- 
ticable, be transferred to the proper officers of their own State. 

The several courts of record in the State shall be authorized to commit, 
for safe keeping and treatment, to either hospital for the insane, any 
person who shall be under charge of, or convicted before such court of, 
any crime punishable by imprisonment in the State Prison and awaiting 



538 APPENDIX — WISCONSIN. 

hearing, trial, conviction, or sentence, on account of alleged insanity at 
the time of the commission of such crime, or at any time afterwards and 
prior to sentence. Whenever it is found by an examination duly made 
that such a patient is no longer insane, the judge of the court from which 
such person was sent, and the district attorney of the proper county, 
shall be notified, and it shall be the duty of such judge to make an order 
for the removal of such peison to the common jail of the county from 
Avhich such person was sent, to be detained in such jail until further dealt 
with according to law, or until discharged therefrom in pursuance of law. 

Whenever any person tried for any criminal oiFence is acquitted on the 
ground that he was insane at the time of the alleged offence, if he has 
recovered his sanity at the time of trial, he shall be discharged, but, if he 
is still insane, he shall be confined in one of the State hospitals for the 
insane, to be kept as other patients are kept and treated therein. 

When any person is indicted or informed against for any offence, if 
there is a probability that such accused person is at the time of trial in- 
sane and incapacitated to act for himself, the court shall, in a summary 
manner, make inquisition by a jury or otherwise, as it deems most proper. 
If it is thus found that such accused person is insane, his trial shall be 
postponed indefinitely, and the court shall thereupon order that he be 
confined in one of the State hospitals for the insane. Upon the recovery 
of such person, he shall be committed to the county jail of the county 
where the indictment or information is pending, or held to bail for his 
appearance at the next succeeding term of said court for trial of such 
offence. If the accused is found to be incurably insane, he shall be treated 
and disposed of as other cases of incurable insanity according to law. 

Whenever it shall appear to the satisfaction of the Governor by the 
representation of the warden and directors of the State Prison, and by 
examination, that any person confined therein has become insane during 
his imprisonment, and is still insane, he may make an order that such 
insane person be confined and treated in one of the State hospitals for 
the insane, and, upon his recovery, if before the expiration of his sentence, 
that he be returned to the State Prison. 

Insane criminals and persons acquitted of crime on the ground of in- 
sanity, may be transferred to the Milwaukee County Asylum for the In- 
sane as well as to the State asylums. 

Whenever it is made to appear to a county judge, by a petition of a 
majority of the supervisors of any town, of the common council of any 
city, or of the board of trustees of any village, that the public safety re- 
quires the close custody of any poor insane person of such town, city, or 
village, the judge shall direct the sheriff forthwith to take and confine 
such insane person in some proper place specified. Such insane person, 
when so confined, shall be subject to the directions of the said judge, and 
shall receive such care, attention, and treatment as such judge shall deem 
proper and necessary. 

Whenever there is not room in the State asylums for the insane of any 
county, such county may establish a county insane asylum. Upon the 
completion of such asylum, all inmates of the State institutions for the 
insane committed from, or belonging to, such county, held as chronic or 
incurable, and all insane inmates of the poor-house of such county, and 



APPENDIX — WYOMING. 589 

all other persons belonging to said county and duly adjudged to be in- 
sane, may be transferred to said county asylum : provided, however, that 
when any patient committed to the county asylum is found to belong to 
the class defined as acute insane, and to require ■ permanent and special 
treatment for the purpose of cure, such person may be transferred to the 
State hospitals for the insane. When there is any room in any such 
county insane asylum for more than the patients of the county, patients 
from any other county may be received and cared for. A portion of the 
expense of erecting such county insane asylums, and of keeping patients 
therein, is paid by the State upon certain conditions and stipulations. 
Whenever any county has not made suitable provisions for the proper 
and humane care of its chronic or its acute insane, the board of charities 
or reform may direct the removal of either class of said insane to any 
county asylum, or to any other county possessing suitable accommoda- 
tions therefor for care or medical treatment, as the circumstances seem 
to require. 

Corporations may be formed for maintaining private insane asylums 
for the care and treatment of insane and feeble-minded persons. Any 
insane or feeble-minded person may, upon the written request of the 
guardian, or any friend of such person, be committed to any such private 
hospital or asylum in the same manner that insane persons are committed 
to the State Hospital for the Insane. 

Insane or feeble-minded persons may voluntarily place themselves 
under the care and treatment of any such hospital, asylum, or institution. 

All such private asylums are subject to substantially the same rules 
and provisions for supervision and visitation as the State hospitals for the 
insane. 

Any person neglecting or abusing an inmate of an asylum for the in- 
sane shall be liable to a fine of $200, or one year's imprisonment. 



WYOMING.^ (Territory.) 

There is no insane asylum in Wyoming. Patients are sent to the 
Iowa Hospital for the Insane, and elsewhere. Each county has the 
responsibility of caring for, and paying the expenses of^ its pauper 
insane. 

If information in writing be given to the probate judge that any per- 
son in the county is an idiot, lunatic, or person of unsound mind, and 
praying that an inquiry thereinto be had, the court, if satisfied that there 
is good cause for the exercise of its jurisdiction, shall cause the facts to 
be inquired into by a jury. If the court is not in session, a special term 

1 The Compiled Laws of Wyomino-, 1876, pp. 35, 161, 162, 248, 249, 280, 295, 472- 
476. Session Laws of Wyoming, 1882, pp. 132, 133. 



540 APPENDIX — WYOMING. 

may be called for the purpose of holding an inquiry. The probate court 
may cause the person alleged to be of unsound mind to be brought before 
it, in its discretion, in the course of the proceedings. Whenever any 
judge of the probate court, justice of the peace, sheriff, coroner, or con- 
stable shall discover any person, resident of his county, to be of unsound 
mind, it shall be his duty to make application to the probate court, and 
thereupon like proceedings shall be had as in the case of information by 
unofficial persons. If it be found by the jury that the person inquired 
about is of unsound mind, and incapable of managing his affairs, the court 
shall appoint a guardian of the person and estate of such person. 

The court may, if just cause appears, at any time during the term at 
which an inquisition is had, set the same aside, and cause a new jury to 
be impanelled to inquire into the facts ; but when two juries concur in 
any case, the verdict shall not be set aside. 

Every guardian of a person of unsound mind shall give a bond condi- 
tioned that he will take due and proper care of such insane person and 
of his property, and will faithfully do and perform all things enjoined 
upon him by the order of the court. Every such guardian shall take 
charge of the person committed to his charge, and provide for his support 
and maintenance. 

If any person by lunacy or otherwise shall be furiously mad, or so far 
disordered in his mind as to endanger his own person, or the person or 
property of others, it shall be the duty of his guardian, or other person 
under whose care he may be, to confine him in some suitable place until 
the next sitting of the probate court of the county, which shall make such 
order for the restraint, support, and safe keeping of such person as the 
circumstances may require. 

If any such person furiously mad shall not be confined by the person 
having charge of him, or there be no person having such charge, any 
judge of a court of record, or any two justices of the peace, may cause 
such insane person to be apprehended, and may employ any person to 
confine him in some suitable place until the probate court shall make 
further order therein. 

If any person shall allege in writing, verified by oath, that any person 
declared to be of unsound mind has been restored to his right mind, the 
court by which the proceedings were had shall cause the facts to be in- 
quired of by a jury. If it shall be found that such person has been 
restored to his right mind, he shall be discharged from care and custody. 

Any person that becomes lunatic or insane after the commission of a 
crime or misdemeanor ought not to be tried for the offence during the 
continuance of the lunacy or insanity. If, after verdict of guilty, and 
before judgment pronounced, such person becomes lunatic or insane, no 
judgment shall be given while such lunacy or insanity continues. If, 
after judgment and before execution, such person becomes insane, then, 
in case the punishment be capital, the execution thereof shall be stayed 
until the recovery of such person from the insanity. In all these cases, 
it shall be the duty of the court to impanel a jury to try the question 
whether the accused be at the time of impanelling insane or not. 

If any convict sentenced to the punishment of death shall appear to 
be insane, the sheriff shall give notice to a judge of the district court of 



APPENDIX — UNITED STATES. 541 

the judicial district, and shall summon a jury of twelve men to inquire 
into such insanity, at a time and place fixed by the judge, and shall give 
notice to the prosecuting attorney. If it be found that the convict is 
insane, the judge shall suspend the execution of the convict until such 
time as the Governor shall direct his execution. , The Governor shall be 
notified of the proceedings and the finding, and, as soon as he is con- 
vinced that the convict has become of sound mind, he may issue a warrant 
appointing a time for his execution. 



UNITED STATES.^ (District of Columbia.) 

The chief executive ofiicer of the Government Hospital for the Insane 
of the Army and Navy of the United States and of the District of 
Columbia is the superintendent, appointed by the Secretary of the 
Interior. 

He shall, upon the order of the Secretary of War, the Secretary of 
the Navy, and the Secretary of the Treasury respectively, receive and keep 
in custody, until they are cured or removed by the same authority which 
ordered their reception : (1) Insane persons belonging to the army, 
navy, marine corps, and revenue cutter service. (2) Civilians employed 
in the quartermaster's and subsistence departments of the army, who 
may be, or may become, insane while in such employment. (3) Men 
who while in the service of the United States, in the army, navy, or 
marine corps, have been admitted to the hospital and have been dis- 
charged on the supposition that they were cured, and who have within 
three years after such discharge become again insane from causes exist- 
ing at the time of such discharge, and have no adequate means of support. 
(4) Indigent insane persons who have been in either of the said services 
and have been discharged therefrom on account of disability arising from 
such insanity. (5) Indigent insane persons who have become insane 
within three years after their discharge from such service from causes 
which arose during and were produced by such service. 

Also persons in the marine-hospital service becoming insane may be 
admitted to the Government Hospital for the Insane upon the order 
of the Secretary of the Treasury. Any inmate of the National Home 
for Disabled Volunteer Soldiers who is or may become insane, shall upon 
an order of the President of the Board of INIanagers of the National 
Home be admitted to said insane hospital and treated therein. The 
Secretary of the Navy may cause persons in the naval service, or marine 
corps, who become insane while in the service, to be placed in such hos- 
pital for the insane as in his opinion will be most convenient and 

1 Revised Statutes of the United States, 1878-1874, pp. 263, 945-948. Supplement to 
the Revised Statutes of the United States, Vol. I., 1874-1881, pp. 104, 191, 289, 461, 
569. United States Statutes, 1881-1882, pp. 329, 330. 



542 APPENDIX — UNITED STATES. 

best calculated to effect a cure ; and he is not restricted to the Govern- 
ment Hospital for the Insane. 

All indigent insane persons, residents in the District of Columbia at 
the time they became insane, shall be entitled to the benefits of the hos- 
pital for the insane, and shall be admitted on the order of the executive 
authority of the District. The Secretary of the Interior may grant an 
order for admission into the hospital, when application is made in writing 
by a member of the board of visitors, accompanied by the certificate of a 
judge of the supreme court for the District of Columbia, or of any justice 
of the peace of the District. It must appear by this certificate that two 
respectable physicians, residents of the District, appeared before said 
judge or justice and deposed in writing that they knew the person alleged 
to be insane; that, from personal examination, they believed him to be 
insane and a fit subject for treatment in the hospital; and that he was a 
resident of the District when seized with the mental disorder then afflict- 
ing him. It must further appear by said certificate that two respectable 
householders, residents of the District, appeared before said judge or 
justice and deposed in writing that they knew the person alleged to be 
insane, and from personal examination believed such insane person 
unable to support himself or himself and family, if he have one, and 
unable to pay his board in the hospital. The affidavits of said physicians 
and householders shall accompany the certificate of the judge or justice. 

The application must be made within five days after the date of the 
affidavits, and it must appear that the visitor applying has examined the 
affidavits and certificate. It shall be the duty of such visitor to withhold 
his application if he has reason to doubt the indigence of the insane 
person. 

The order of the Secretary of the Interior being granted, any police 
officer or constable may assist in carrying such insane person to the 
hospital. 

If the patient is found to have some property, he may be required to 
pay such part of his expenses in the hospital as may be just and reason- 
able. 

Any indigent insane person who did not reside in the District at the 
time he became insane, may be received into the hospital in like manner, 
to stay temporarily, until it can be ascertained who his friends are, or 
whence he came. 

Whenever there are vacancies, private patients from the District may 
be received, the rate of board to be determined by the visitors. The pay 
patients may be received on the certificate of two respectable physicians 
of the District, stating that they have personally examined the patient, 
and believe him to be insane, and a fit subject for treatment in the hos- 
pital. There must be also a written request for the admission from the 
nearest relatives, legal guardian, or friend of the patient. The request 
must be made within five days of the date of the certificate of insanity. 

If any person will give bond, with sufficient security, to restrain and 
take care of any pay, or any indigent, insane person, not charged with a 
breach of the peace, whether in the hospital or not, the supreme court of 
the District, or any judge thereof, in vacation, may deliver the patient to 
him, to be kept until restored to sanity. 



APPENDIX — UNITED STATES. 543 

If any person charged with crime be found in the court before which 
he is so charged to be an insane person, such court shall certify the same 
to the Secretary of the Interior, who may order such person to be con- 
fined in the Hospital for the Insane. 

Any person becoming insane during the continuance of his sentence 
in the United States Penitentiary shall have the same privilege of treat- 
ment in the hospital during the continuance of his mental disorder as is 
granted above to persons who escape the consequences of criminal acts 
by reason of insanity. If it be the opinion both of the physician to the 
penitentiary and the superintendent of the hospital that such insane con- 
vict is so depraved and furious in his character as to render his custody 
in the hospital insecure, and his example pernicious, he shall not be 
received. 

When any person, confined in the Hospital for the Insane, charged 
with crime, and subject to be tried therefor, or convicted of crime, and 
undergoing sentence therefor, shall be restored to sanity, the superinten- 
dent of the hospital shall give notice to the judge of the criminal court, 
and deliver him to the court, in obedience to the proper precept. 

No insane person, not charged with any breach of the peace, shall be 
confined in the United States Jail, in the District of Columbia. 

Upon the application of the Attorney-General, the Secretary of the 
Interior shall transfer to the Government Hospital for the Insane, in the 
District of Columbia, all persons who, having been charged with offences 
against the United States, are in the actual custody of its officers, and 
all persons who have been or shall be convicted of any offence in a court 
of the United States, and are imprisoned in any State prison or peniten- 
tiary of any State or Territory, and who, during their term of imprison- 
ment, have or shall become insane. In all cases where there shall not be 
accommodation for such insane convicts in the Insane Asylum of the 
District of Columbia, or if, for other reasons, the Attorney- General is of 
opinion that such insane person should be placed at a State insane asylum, 
rather than at said District Asylum, then the Attorney-General shall 
have power, in his discretion, to contract with any State insane or lunatic 
asylum within the State in which such convict is imprisoned for his care 
and custody while he remains insane. Whenever such insane convict 
shall be restored. to sanity, he shall be returned to the prison or peniten- 
tiary from which the transfer was made, provided the term of imprison- 
ment shall not have expired. 

The questions of sanity in all such cases shall be determined in accord- 
ance with the rules and regulations of existing laws, State or national, 
on the subject, applicable to the prison, penitentiary, or asylum where 
such convict shall be confined. 



INDEX. 



ACUTE mania, 136 
Adolescence, insanity of, 379 
mortality in, 387 
progress in, 386 
recovery in, signs of, in, 382 
symptoms of, 379 
treatment of, 383 
psychology of, 375 
Affections cooled by insanity, 140 
Affective insanity, 231 
Ague, insanity from, 417 
Alabama, laws respecting insane, 439 
Alcohol a cause of insanity, 312 
Alcoholic degeneration, 317 

insanity, 312 
Alcoholism, acute, 313 

chronic, 315 
Alimentation psychologically considered, 

39 
Alternating insanity, 170 
Alternation in insanity, 170 
Amenorrhoeal insanity, 336 
Amentia, 43, 204 

Anaemia in insanity of lactation, 360 
Anaemic brain, 326, 360 

insanity, 411 
Animal food, its effects on neurotic chil- 
dren, 167, 384 
impulse, 244 
Aphasia, case of, 278 
Appointments in lunacy, 36 
Arizona, laws respecting insane, 440 
Arkansas, laws respecting insane, 441 
Arteries, lesions of, in brain syphilis (Plate 

VIII. Fig. 1), 305 
Arteritis, syphilitic, 302, 305, 306 
Asthma, insanity of, 416 



BAILLAKGER first described circular 
insanity, 171 

Baths, hot, in mania, 145, 155 
in mehmcholia, 120, 211 
Turkish, in melancholia, 120, 211 

Belladonna as a sleep producer, 169 

Benedick on the brains of criminals, 232 

Bird, G., on oxaluria, 415 

Blistering in mania, 154 

Boils in mania, 154 

Brain, auannic, 326 



Brain, functions of, as related to mental 
diseases, 46-49 
pathological disorders of, 45 
Bright's disease, insanity in, 414 
Bromides as hypnotics, 168 
in circular insanity, 187 
in epilepsy, 295, 297 
in mania, 146 
Brown, J. J., on a new lesion in acute 
mania (Plate VII. Fig. 2; Plate 
VIII. Figs. 1, 2, 5), 92 
on lesions in senile dementia, 408 
on syphilitic arteritis, 305 
Bucknill and Tuke on post-febrile in- 
sanity, 417 



CADELL, Dr., his case of syphilitic in- 
sanity, 802 
California, laws respecting insane, 442 
Campbell, J. A , cases of melancholia, 74 

413 
Camphor as a sleep producer, 147, 169 
Cannabis Indica in alternating insanity 
187 
in mania, 146 
in melancholia, 94 
Cat, maternal instinct in, 235 
Certificates for Curator Bonis^ 427 

for treatment in private houses, 424 
of lunacy, 35, 424 
of sanity, 427 
Chancery, affidavits for, 427 
Children, insanity in sensitive, 55, 121 
Chloral as a sleep producer, 168 
insanity from use of, 318 
use and dangers of, in mania, 146 
Chorea, delirium of, 824 

its connection with rheumatism, 319 
Choreic insanity in early youth, 324 
its epidemic forms, 325 
prognosis in, 324 
treatment of, 325 
Circular insanity, 170 
causes of, 184 
duration of, 174-177 
frequency of, 183 
its nature, 171 
pathology of, 187 
symptoms of, 180 



*l 



35 



546 



INDEX, 



Circular insanity, termination of, 184 

treatment of, 185 
Clark, Campbell, his case of hydrocephalic 

idiocy, 215 
Classification of insanity, 44, 45 
Climacteric insanity, 388 

pathological appearances in, 393 
prognosis in, 393 
statistics of, 393 
suicidal longings in, 389 
symptoms of, 389 
Climacteric in man, 391 
in woman, 389 
psychology of, 388 
Colorado, laws respecting insane, 444 
Competitive examinations, mischief from, 

121 
Congestion of brain in acute mania (Plate 

III.), 156 
Conium in acute mania, 147 
Connecticut, laws respecting insane, 445 
Connubial affection altered in climacteric 

insanity, 388 
Conscience a brain quality, 256 
Consciousness lost in epilepsy, 295 
in mania, 138 
in stupor, 219 
Convolutions, supply of blood to (Plate 
YII. Fig. 5), ■'48 
their structure and function, 46 
Convulsive melancholia, 98 
Cretinism, 216 
Croom, Dr. Halliday, on perversions of 

appetites, during menstruation, 336 
Curator Bonis, appointment of, 427 
Cyanosis, insanity of, 416 



DAKOTA, laws respecting insane, 448 
Deaf-mutism, an hereditary neurosis, 
216 
Decoration, insane, 190 
Delaware, laws respecting insane, 450 
Delirium in young children, 421 
Delirium tremens, 50, 313 
De lunatico inquireyido, 427 
Delusions, insane, defined, 189 
should be tested, 50 
their legal importance, 201 
of melancholia, in idiots, 188 

list of, 88 
sane and insane, 88 
Delusional mania, 157 

melancholia, 72 
Dementia, alcoholic, 316 
its varieties, 206 
organic, 206, 276 
primary, 212 
prognosis in, 209 
secondary, 206 
senile, 395 
Demonomania, 84 
Deprivation, idiocy by, 216 

insanity by, 418 
Destructive impulse, 248 
Diabetic insanity, 411 



Diabolic possession, superstition of, 84 

Diathesis, the insane, 257 
doctrines of, 39 

Diet {see Animal Food) in circular in- 
sanity, 185 
in melancholia, 117 

Dietetic management of the nisus genera- 
iivus, 346 

Dipsomania, 250 

Dipsomaniacs, laws respecting, 447 

District of Columbia, laws respecting in- 
sane, 541 

Douse on prevalence of syphilis, 301 

Dininkards, laws respecting, 447, 462 

Duncan, Dr. Mathews, on fecundity, 375 



EDUCATIO^^ of girls, 369 
of neurotic children, 433 
Eggs in the treatment of acute mania, 148 
Electricitv, delusions of being tortured 
by; 83 
in detecting feigned insanity, 431 
in stupor, 211, 224 
Enfeeblement, morbid, 204 
Epileptic insanity, 286 

counter-irritations in, 296 
hallucinations in, 293 
pathology of, 292, 295 
prevalence of, 297 
religious emotionalism in, 288, 

289 
suicidal impulses in, 293 
treatment of, 295 
suicide of an, 294 
Epileptics, criminal, 288 
Epileptiform convulsions in general paral- 
ysis, 268 
impulse, 243 
melancholia, 92 
Epilepsy compatible with sanity, 286 

masked, 287 
Epithelial granulations in ventricles (Plate 

YII. Fig. 3), 274 
Ergot in melancholic stupor, 224 
Erotomania, 236 
Esquirol's classification, 42 
Exaltation, physiological, 123 
Examining patients, rules for, 49 
Excited melancholia, 90 



FALKET on circular insanity, 171 
Fattening in insanity of adolescence, 
383 
Fears, morbid, 64, 199 
Feeding, forcible, 107 
Ferrier on brain localization, 82 
Flesh meat. See Animal Food. 
Florida, laws respecting insane, 451 
Folic a double forme, 170 
circulaire, 170 

commencement of, 184 
pathology of, 187 
termination of, 184 
treatment of, 185 



INDEX. 



547 



Folie raisonnante, 135, 171 
Friends, Society of, insanity in, 381 



GENERAL paralysis, definition of, 260 
etiology and distribution, 269, 276 
its nature, 275 
pathology of, 272 
prevalence and ages (Plate YI.), 

276 
stages of, 260 

varieties, pathological, 265 
symptomatological, 267 
Georgia, laws respecting insane, 452 
Gouty insanity, prognosis of, 325 
termination in, 326 



H HEMATOMA auris, 97, 265, 37£ 
Hallucination, a, defined, 139 
Hemiplegia, 277 

alternating, 92 
Hereditary tendency, 39 
of melancholic ( 
Home treatment expensive, 51 

its advantages, 52 
Homicidal impulse, 244 
mania, 162 
melancholia, 104 
Hygiene in neurotic children, 432 
Hyoscyamine in mania, 146 
Hyoscyamus as a hypnotic, 169 
Hyperkinesia, 231 
Hypnotics in insanity, 145 
Hypochondria 55 
Hypochondriacal melancholia, 67 
Hysterical insanity, 340 
statistics of, 341 
Hystero-epilepsy, 340 



TDAHO, laws respecting insane, 454 
Idiocy, by deprivation, 217 
definition of, 212 
eclampsic, 214 
epileptic, 214 
genetous, 213 
hydrocephalic, 215 
inflammatory, 215 
microcephalic, 215 
paralytic, 214 
traumatic, 215, 300 
Illegitimacy a cause of puerperal insanity, 

356 
Illinois, laws respecting insane, 455 
Illusion, an, defined, 139 
Imbecility, 212 

congenital, 212 
Impulse, animal, 231 
destructive, 249 
homicidal, 231 
insane, 231 
suicidal, 231 
uncontrollable, 231 
Impulses, morbid, 237 
Impulsive insanity, 231 



Impulsive insanity, a remarkable case of, 

238 
Incoherence in mania (Plate IT.)) 138, 

139 
Indecision, morbid, 60 
Indiana, laws respecting insane, 457 
Inebriate apyluras, 447 
Inhibitory insanity, 231 

power, defective, 231 
Inglis, T., on hystero-epilepsy with in- 
sanity, 340 
Insane impulse, 231 
Insanity, alcoholic, 312 

amenorrhoeal, 336 

anaemic, 411 

by dejirivation, 418 

choreic, 319 

circular, 170 

climacteric, 388 

diabetic, 411 

epileptic, 286 

feigned, 431 

gouty, 325 

hysterical; 340 

inhibitory, 285 

metastatic, 416 

moral, 255 

of adolescence, 397 

of asthma, 416 

of Bright's disease, 414 

of cardiac disease, 416 

of cyanosis, 416 

of exophthalmic goitre, 419 

of lactation, 359 

of lead-poisoning, 421 

of masturbation, 342 

of myxoedema, 419 

of oxaluria, 415 

of phosphaturia, 415 

of pregnancy, 363 

of puberty, 368 

ovarian, 336 

paralytic, 276 

phthisical, 326 

post-connubial, 421 

post-febrile, 416 

puerperal, 349 

rheumatic, 319 

senile, 395 

syphilitic, 301 

traumatic, 298 
Iowa, laws respecting insane, 459 
Ireland, W. W., on idiocy, 212 
Irritabilitv defined, 234 



TACKSON, J. HITGHLINGS, on epi- 
f,/ leptic insanity, 287 

on syphilitic insanity, 301 



KANSAS, laws respecting insane, 462 
Katatonia, 182 
Kentucky, laws respecting insane, 464 
Kleptomania, 45, 236, 251 



648 



INDEX. 



LACTATION, insanity of, 359 
prognosis in, 363 
statistics of, 363 
symptoms of, 360 
treatment of, 361 
Lawlessness, organic, 232 
Laycock, T., on general paralysis, 267 

on organic memory, 138 
Laziness often a disease, 64 
Lead-poisoning, insanity of, 421 
Legal views about insanity, 428 
Louisiana, laws respecting insane, 466 
Lunatics, their number, 35 
Lycanthropia, 236 



MACLAEEN, J,, his case of impulsive 
insanity, 238 
Maine, laws respecting insane, 467 
Major H., on senile brains (Plate VIII. 

rig 4), 408 
Mania a potu, 317 
Mania, 43, 123 

acute, 136 

caused by a new lesion (Plate VIII. 
Fig. 5), 156 

chronic, 157 

definition of, 124 

delusional, 157 

delusions in, 165 

diet in, 144 

ephemeral (transitoria), 161 

first stage of, 137 

homicidal, 162 

in children, 123 

periodic, 170 

prevalence of (Plate VI.), 167 

prognosis of, 165 

prophylaxis in, 167 

recurrent, 170 

second stage of, 137 

simple, 125 

termination of, 166 

treatment of acute, 144, 211 
Marriage in circular insanity, 185 

in niasturbational insanity, 347 

with neurotic persons, 431 
Maryland, laws respecting insane, 470 
Massachusetts, laws respecting insane, 471 
Massage, 63 

Masturbation, insanity of, 342 
bodily signs in, 343 
bromides in, 347 
statistics of, 347 
treatment of, 346 

self-learned, 345 
Maudsley, H., 34 

on phthisical insanity, 328 

on the insane diathesis, 257 
Mechanical restraint in mania, 142 
Medical psychology defined, 34 
Medico-legal duties of medical men in 

mental diseases, 424 
Megalomania, 113, 190 
Melancholia, bodily symptoms of, 114 



Melancholia, causation of, 115 

convulsive, 98 

definition and nature, 56 

delusional, 72 

delusions in, 88 

epileptiform, 92 

excited, 90 

hereditary predisposition in, 115 

homicidal, 104 

hypochondriacal, 67 

inception of, 113 

in children, 421 

lesions in brain in (Plate VII. Fig. 
1), 76, 81, 82, 102 

organic, 100 

prevalence and ages (Plate VI.), 
114 

prognosis of, 67, 115 

prophylaxis of, 121 

religious, 84 

resistive, 94 

simple, 57 

suicidal, 104 

termination of, 116 

treatment of, 117, 211 
Melancholic diathesis, 55 

persons, 54 
Melancholy v. malancholia, 56 
Melancholy, hereditary, 55 
Memory in acute mania, 138 

morbid, 138 
Menstruation in acute mania, 153 

insanity from suspended, 338 

psychology of, 336 
Mental conditions liable to be mistaken 

for insanity, 50 
Metastatic insanity, 416 
Michigan, laws respecting insane, 475 
Mickle on the use of opium, 120 
Milk in acute mania, 144 

in adolescent insanity, 383 

in melancholia, 117 
Minnesota, laws respecting insane, 477 
Mississippi, laws respecting insane, 479 
Missouri, laws respecting insane, 480 
Monomania (mono-psychosis), 43, 44, 
188 

diagnosis of, 200 

of grandeur, 190 

of suspicion, 196 

of unseen agency, 198 

origin of, 201 

prognosis of, 202 

prophylaxis of, 202 

treatment of, 202 
Montana, laws respecting insane, 483 
Moral insanity, 255 

Pritchard's, 171 
Moreau de Tours on human degeneration, 

312 
Morel on delirium in phthisis, 327 

on human degeneration, 312 
Morselli on suicide, 106 
Mouth-openers, 107 
Myxcedema, 419 



INDEX 



649 



VTAKCOTICS in mania, 146 

iS in melancholia, 120 

Nebraska, laws respecting insane, 485 

Necrophilism, 236 

Neuralgia analogous to melancholia, 42 

Neurasthenia, 63 

Neurosis, insane, 45 

spasmodic, 45 
Nevada, lav/s respecting insane, 488 
New Hampshire, laws respecting insane, 

489 
Newington, Hayes, on alternating hemi- 
plegia, 92 

on anergic stupor, 219 

on mania a potu, 317 

on syphilis as a cause of insanity, 310 

on syphilomatous insanity, 304 
New Jersey, laws respecting insane, 491 
New Mexico, laws respecting insane, 494 
New York, laws respecting insane, 495 
Nitrite of amyl in mania, 146 
North Carolina, laws respecting insane, 
502 



OBSTINACY, morbid, in melancholia, 
94 
Ohio, laws respecting insane, 503 
Old maid's insanity, 339 
Opium useful against sleeplessness, 169 

useless in mania, 146 

useless in melancholia, 120 
Oregon, laws respecting insane, 507 
Organic dementia, 276 

insanity, 275 

melancholia, 100 
Oxaluria,, insanity of, 415 

period of, 415 



PAEALYSIS. See General Paralysis. 
Paralysis of energy, 63 

of feeling, 63 
Paralytic insanity, 276 

analogies, 278 

causes, 277 

congestive and epileptiform at- 
tacks in, 282 

pathology of, 285 

recovery in, 281 

statistics of, 285 

symptoms of, 278 
Pennsylvania, laws respecting insane, 

508 
Periodicity in mental diseases, 170 
Phosphates in melancholia, 117 
Phosphaturia, insanity of, 415 
Phosphorus in mental depression, 117 
Phthislca spes^ 334 
Phthisical insanity, 326 

pathology of, 331, 332 

prognosis in, 334 

statistics of, 327 

symptoms of, 328 
Phthisis common among the insane, 327 
mental condition in, 329 



Pia mater adherent in general paralvsis 

(Plate I.), 273 
Planomania, 236 

Podagrous insanity. See Gouty Insanity. 
Post-connubial insanity, 421 
Post-febrile insanity, 416 
Pregnancy, insanity of, 363 

character of, 364 

prognosis in, 366 

statistics of, 367 

suicidal tendency in, 366, 367 
psychology of, 363 
Pritchard's moral insanity, 126 
Prout on oxaluria, 415 
Psychalgia, 43 
Psychlampsia, 43, 123 
Psychocoma, 44, 217 
Psychokinesia, 44, 231 

general, 238 
Psychology, medical, 34 
Psychoneurosis, 44 
Psychoparesis, 43, 204 
Psychorhythm, 44, 170 
Puberty, insanity of, 368, 373 

period of, 368 
Puerperal insanity, definition of, 349 

frequency of, 355 

heredity in, 356 

pathology of, 355 

prognosis in, 358 

statistics of, 355 

symptoms of, 350 
Pyromania, 236 



QUININE in melancholia, 117, 211, 
354 



RAYNEK on the insanity of lead -poison- 
ing, 421 

Reasoning insanity, 171 

Relapses in insanity, 170 

Religious melancholia, 84 

Reproduction psychologicallv considered, 
40, 371 

Resistive melancholia, 94 

Responsibility, legal, 233 

Restraint in mania, 142 

Rheumatic insanit}', 319 

Rhode Island, laws respecting insane, 515 

Robertson, A., on the insanity of lead- 
poisoning, 421 



O ATYRIASIS, 236 

U Savage on the insanity of load-poison- 
ing, 421 
Self-control, sane lack of, 231 
Senile insanity. 395 

hallucinations of hearing in, 404 

management of, 409 

motor restlessness in, 397 

pathology of, 406 

prognosis in, 405 

statistics of, 396 



550 



INDEX. 



Senile insanity, treatment of, -409 

Senility, psychology of, 395 

Sensibility diminished in mania, 142 

Septic inflammations in mania, 154 

Septicaemia and puerperal insanity, 355 

Shower-baths, 211 

Skae, C. H., cases of trephining, 299 

Skae, D., his classification, 45 

Smith, Willie, the homicide, 163 

Somnambulism, 421 

South Carolina, laws respecting insane, 

518 
Stewart, H. G., on delusional syphilitic 
insanity, 303 
on monomania of unseen agency, 194 
Stewart, T. G., on insanity from Bright's 

disease, 414 
Stimulants in melancholia, 118 
Strychnine in mania, 147 
in melancholia, 117 
in threatened dementia, 211 
Study of mental diseases, 34-42 
Stupor, anergic, 226 
causation of, 230 
definition of, 217 
epileptic, 230 
melancholic, 220 
paralytic, 230 
prognosis in, 230 
secondary, 229 
treatment of, 230 
varieties of, 219 
Suicidal impulse, 247 

frequency of, 110 
melancholia, 104 
Suicide, a determined, 108 
case of, 217 
in an epileptic, 294 
letter of a, 108 

modes of committing, 105-107 
Sunstroke a cause of insanity, 298 
Suspicion, monomania of, 196 
Sydenham on insanity from ague, 417 
Symptomatological classification, 44 
Syphilis, its prevalence, 301 
Syphilitic insanity, 302 

cephalalgia in, 309 
delusional, 303 
pathology of, 304, 308, 311 
prognosis in, 311 
secondary, 302 
syphilomatous, 304, 307 
treatment of, 309 
vascular, 304 



TEMPEKAMENTS, doctrine of, 39 
melancholic, 55 
sanguine, 123 
Temperature, in children, 123 
in insanity, 49 
in mania, 128, 141 
in puerperal insanity, 356 
Tennessee, laws respecting insane, 520 
Tests of insanity made by lawyers, 428 
Texas, laws respecting insane, 522 
Traumatic idiocy, 300 
insanity, 298 

prevalence of, 300 
trephining in, 299 
Tuke, D. Hack, on stupor, 218 
Tuke, J. Batty, his statistics of puerperal 
insanity, 359 
on lactational insanity, 362 
Tumors of brain and insanity, 281 
Twins, with hereditary neurosis, 168 



UNCONTEOLLABLE impulse, 231 
United States, laws respecting in- 
sane, 541 
Utah, laws respecting insane, 524 



YASO-MOTOE spasm, 102 
Y Vermont, laws respecting insane, 

526 
Verriicktheit primare, 135, 259 
Visceral melancholia, 74 

pathology of (Plate VII. Pig. 1), 
82 
Volitional insanity, 231 



WASHINGTON, laws respecting in- 
sane, 531 
West Virginia, laws respecting insane, 

533 
Wilkes on insanity from Bright's disease, 
414 
on syphilitic afi'ections, 301 
Will-making, 429 

Wisconsin, laws respecting insane, 585 
Wyoming, laws respecting insane, 539 



YELLOWLEES, D., his case of homi- 
cidal mania, 163 
his case of somnambulism, 422 



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A Practical Treatise on Fractures. By Lewis a. Stimson, b.a., m.d., 

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Illustrations of the Inflnence of the Mind upon the Body in Health and 

Disease. Designed to elucidate the Action of the Imagination. By Daniel Hack 
TuKE, M.D., Joint Author of the Manual of Psychological Medicine, etc. New 
edition. Thoroughly revised and rewritten. In one handsome octavo volume of 
467 pages, with two colored plates. Cloth, $3.00. Just Ready. 

In ail medicine that pertains to psychological subjects tion We heartily wish this volume could find a place 
no one occupies a more exalted position than the well- in ever>'^ physician's library, for here may be found a 
known author of this volume. His investigations in physiological explanation of many perplexing phe- 
regard to mental phenomena always command atten- . nomena. — Cincinnati Lancet and Clinic,^l2iT. 29,1884. 



Preventive Medicine. By B. W. Richardson, m. a., m. d., ll. d., 

F.R.S., F.S.A., Fellow of the Royal College of Physicians, London. In one octavo 
volume of 729 pages. Cloth, $4.00; leather, $5.00; very handsome half Russia, 
raised bands, 55- 50. Just Ready. 

The volume before us is a classical production, com- of its kind that has ever been published. It is scientific, 

prehensive in scope, logical in arrangement, rich in methodical and practical. The time of its publication 

material, sound in doctrine, and instructive in its is most opportune. — The Medical News, March 22, 

teachings. This book, taken as a whole, is the best 1884. 



Legal Medicine. By Charles Meymott Tidy, M.B., F.C.S., Professor 
of Chemistry and of Forensic Medicine and Public Health at the London Hospital, 
etc. Volume II. Legitimacy and Paternity, Pregnancy, Abortion, Rape, Indecent 
Exposure, Sodomy, Bestiality, Live Birth, Infanticide, Asphyxia, Drowning, Hanging, 
Strangulation, Suffocation. ^Making a very handsome imperial octavo volume of 
529 pages. Cloth, 36,00 ; leather, $7.00. Just Ready. 

Volume I. Containing 664 imperial octavo pages, with two beautiful colored 
plates. Cloth, $6.00 ; leather, I7.00. Recently Issued. 

He whose inclinations or necessities lead him to as- ' due attention to the most recent advances in medical 
sume the functions of a medical jurist wants a book science. Mr. Tidy's work bids fair to meet this need 
encyclopsedic in character, in which he maj' be reason- satisfactorily. — Boston Medical and Surgical Journal, 
ably sure of finding medico-legal topics discussed with February 8, 1883. 
judicial fairness, with sufl&cient completeness, and with •■ 



Nervous Diseases; Their Description and Treatment. By Allan McLane 
Hamilton, M.D., Attending Physician at the Hospital for Epileptics and Paralytics, 
Blackwell's Island, N. Y., and at the Out-Patients' Department of the New York 
Hospital. Second edition, thoroughly revised and rewritten. In one octavo volume 
of 598 pages, with 72 illustrations. Cloth, S4.00. 

When the first edition of this good book appeared we best of its kind in any language, which is a handsome 

gave it our emphatic endorsement, and the present endorsement from an exalted source. The improve- 

edition enhances our appreciation of the book and its ments in the new edition, and the additions to it, will 

author as a safe guide to students of clinical neurology, justify its purchase even by those who possess the old. 

One of the best and most critical of English neurologi- — Alienist and Neurologist, April, 1882, 
cal journals. Brain, has characterized this book as the 



A System of Midwifery, including the Diseases of Pregnancy and the 
Puerperal State. By William Leishman, M.D., Regius Professor of Midwifery in 
the L'niversity of Glasgow, etc. Third American edition, revised by the Author, with 
additions by John S. Parry, M.D., Obstetrician to the Philadelphia Hospital, etc. 
In one large and very handsome octavo volume of 740 pages, with 205 illustrations. 
Cloth, $4.50; leather, $5.50; very handsome half Russia, raised bands, $6.00. 



To the American student the work before us must 
prove admirably adapted. Complete in all its parts, 
essentially modem in its teachings, and with demon- 



strations noted for clearness and precision, it will gain ' Surgical Journal , March 



in favor and be recognized as a work of standard 
merit. The work cannot fail to be popular and is 
cordially recommended. — Neiv Orleans Medical and 



A Practical Treatise on Diseases of the Skin. For the use of Students 

and Practitioners. By J. Nevixs Hyde, A.M., M.D., Professor of Dermatology and 
Venereal Diseases in Rush Medical College, Chicago. In one handsome octavo 
volume of 570 pages, with 66 beautiful and elaborate illustrations. Cloth, S4.25 ; 
leather, $5.25. 

The author has given the student and practitioner a to our literature and a reliable guide to students and 
work admirably adapted to the wants of each. We practitioners in their studies and practice —American 
can heartily commend the book as a valuable addition Journal of the Medical Sciences, July, 1883. 



HENRY C LEAS SON & CO., PHILADELPHIA. 



HENEY C. LEA'S SON & CO.'S 

(LATE HENRY C. LEA) 

CLASSIFIED CATALOGUE 

O P 

MEDICAL AND SURGICAL 

PUBLICATIONS. 



In asking the attention of the profession to the works advertised in the following pages, 
the publishers would state that no pains are spared to secure a continuance of the confi- 
dence earned for the publications of the house by their careful selection and accuracy and 
finish of execution. 

The large number of inquiries received from the profession for a finer class of bindings than is 
usually placed on medical books has induced us to put certain of our standard publications in 
half Russia ; and, that the growing taste may be encouraged, the prices have been fixed at so small 
an advance over the cost of sheep as to place it within the means of all to possess a library that 
shall have attractions as well for the eye as for the mind of the reading practitioner. 

The printed prices are those at which books can generally be supplied by booksellers 
throughout the United States, who can readily procure for their customers any works not 
kept in stock. Where access to bookstores is not convenient, books will be sent by mail 
postpaid on receipt of the price, and as the limit of mailable weight has been removed, no 
difficulty will be experienced in obtaining through the post-office any work in this cata- 
logue. No risks, however, are assumed either on the money or on the books, and no pub- 
lications but our own are supplied, so that gentlemen will in most cases find it more con- 
venient to deal with the nearest bookseller. 

A handsomely illustrated catalogue will be sent to any address on receipt of a three-ceni 
stamp. 

HENKY C. LEA'S SON & CO. 

Nos. 706 and 708 Sansom St., Philadelphia, April, 1884. 



PROSPECTUS FOR 1034. 

A WEEKLY MEDICAL JOURNAL 



SUBSCRIPTION RATES. 

The Medical News . FiveDollars. 

The American Journal of the Medical Sciences . Five Dollars. 

COMMUTATION RATES. 

The Medical News \ Nine Dollars per 

The American Journal of the Medical Sciences / annum, in advance. 

THE MEDICAL NEWS. 

A National Weekly Medical Periodical, containing: 28 to 32 Quarto 
Pajres of Heading Matter in Each Issue. 

In making the change, two years since, from a monthly to a weekly, those in charge 
of The Medical News, proposed to furnish the profession what it had never before 
enjoyed — a journal national in the widest sense of the word, devoted to the highest ideals 
of professional morals and honor, an unsparing enemy of quackery and fraud, a soicntitic 
magazine in elaboration, and a newspaper in energy and vitality. They bolievc that in 
every respect it has fulfilled its promises. Its readers and contributors arc found in every 
State and Territory; its Editorial Stall" includes some of the brightest minds in the 



4 Henry C. Lea's Son & Co.'s Publications — Dictionaries. 

nUJS^GLISOW, BOBLBY, 31. B., 

Late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. 

MEDICAL LEXICON; A Dictionary of Medical Science: Containing 

a concise explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol- 
ogy, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris- 
prudence and Dentistry, Notices of Climate and of Mineral Waters, Formulae for Officinal, 
Empirical and Dietetic Preparations, with the Accentuation and Etymology of the Terms, 
and the French and other Synonymes, so as to constitute a French as well as an English 
Medical Lexicon. A new edition, thoroughly revised, and very greatly modified and 
augmented. By Richard J. Dunglisox, M. D. In one very large and handsome royal 
octavo volume of 1139 pages. Cloth, §6.50 ; leather, raised bands, $7.50 ; very handsome 
half Eussia, raised bands, $8. 

The object of the author, from the outset, has not been to make the work a mere lexi- 
con or dictionary of terms, but to afford under each woid a condensed view of its various 
medical relations, and thus to render the work an epitome of the existing condition of 
medical science. Starting with this view, the immense demand which has existed for the 
work has enabled him, in repeated revisions, to augment its completeness and usefulness, 
until at length it has attained the position of a recognized and standard authority wherever 
the language is spoken. Special pains have been taken in the preparation of the present 
edition to maintain this enviable reputation. The additions to the vocabulary are more 
numerous than in any previous revision, and particular attention has been bestowed on the 
accentuation, which will be found marked on every word. The typographical arrangement 
has been greatly improved, rendering reference much more easy, and every care has been 
taken with the mechanical execution. The volume now contains the matter of at least 
four ordinary octavos. 

A book of which every American ought to be i work has been well known for about forty years, 

proud. When rhe learned author of the work i and needs no words of praise on our part to recom- 

passed away, probably all of us feared lest the book ; mend it to the members of the medical, and like- 

should not maintain its place in the advancing | wise of the pharmaceutical, profession. The latter 

science whose terms it defines. Fortunately, Dr. i especially are in need of a work which gives ready 

Richard J. Dunglison, having assisted his father in | and reliable information on thousands of subjects 

the revision of several editions of the work, and i and terms which they are liable to encounter in 

having been, therefore, trained in the methods I pursuingtheir daily vocations, but with which they 

and imbued with the spirit of the book, has been j cannot be expected to be familiar. The work 

able to edit it as a work of the kind should be | before us fully supplies this want. — American Jour- 

edited — to carry it on steadily, without jar or inter- I nal of Pharmacy, Feb. 1S7-4. 

ruption, along the grooves of thought it has trav- ! Particular care has been devoted to derivation 

elled during its lifetime. To show the magnitude j and accentuation of terms. With regard to the 

of the task which Dr. Dunglison has assumed and : latter, indeed, the present edition may be consid- 

carried through, it is only necessary to state that j ©red a complete " Pronouncing Dictionary of 

more than six thousand new subjects have been I Medical Science." It is perhaps the most reliable 

added in the present edition.— P/u/;ade/!i5/«a Medical \ ^^ork published for the busy practitioner, as itcon- 

Tlmes, Jan. 3, 1874. j tains information upon everv medical subject, in 

About the first book purchased by the medical \ ^ P™ ^^^ l^.^'^y ^«<;?s^''} ^"^ '^j/*!^ ^^p'T^^Y^^ *i" 
student is the Medical Dictionary. The lexicon i niirable asitis practical.-^oui/iernJ/eJicaiiJdcord, 



explanatory of technical terms is simply a sine qua 
non. In a science so extensive and with such col- 
laterals as medicine, it is as much a necessity also 
to the practising physician. To meet the wants of 
students and most physicians the dictionary must 



Feb. 1874. 

A valuable dictionary of the terms employed in 
medicine and the allied sciences, and of the rela- 
tions of the subjects treated under each head. It 
well deserves the authority and popularity it has 



be condensed while comprehensive, and practical \ obtained.— British Med. Jour., Oct. 31, 1874. 



while perspicacious. It was because Dunglison' 
met these indications that it became at once the 
dictionary of general use wherever medicine was 
studied in the English language. In no former 
revision have the alterations and additions been 
so great. The chief terms have been set in black 
letter, while the derivatives follow in small caps; 
an arrangement which greatly facilitates reference. 
— Cincinnati Lancet and Clinic, Jan. 10, 1874. 
As a standard work of reference Dunglison's 



Few works of this class exhibit a grander monu- 
ment of patient research and of scientific lore. — 
London Lancet, May 13, 1875. 

Dunglison's Dictionarj'- is incalculably valuable, 
and indispensable to every practitioner of medi- 
cine, pharmacist and dentist. — Westeryi Lancet, 
March, 1874. 

It has the rare merit that it certainly has no rival 
in the English language for accuracy and extent ot 
references. — London Medical Gazette. 



HOBLYW, BICBEABB B., M. B. 

A Dictionary of the Terms Used in Medicine and the Collateral 
Sciences. Revised, with numerous additions, by Isaac Hays, M. D., late editor of 
The American Journal of the Medical Sciences. In one large royal 12mo. volume of 520 
double-columned pages. Cloth, §1.50 ; leather, §2.00. 

It is the best book of definitions we have, and ought always to be upon the student's table — Southern 
Medical and Surgical Journal. 

BOBWBBL, G. F., F. B. A. S., F. C. S., 

Lecturer on Natural Science at Clifton College, England. 
A Dictionary of Science : Comprising Astronomy, Cliemistry, Dynamics, Elec- 
tricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, Mechanics, Meteorology, 
Pneumatics, Soimd and Statics. ' Contributed bv J. T. Bottomlev, M. A., F. C. S., William 
Crookes, F.R.S., F.C.S., Frederick Guthrie, BA., Ph. D., R. A. Proctor, B.A., F.R.A.S., 
G. F. Rodwell, Editor, Charles Tomlinson, F.R.S., F.C.S., and Richard Wornell, M.A., 
B.Sc. Preceded by an Essay on the History of the Physical Sciences. In one handsome 
octavo volume of 702 pages, with 143 illustrations. Cloth, §5.00. 



Henry C. Lea's Son & Co.'s Publications — Conipends, Anat. 5 
HAMTSHOHWE, MJEJSTMT, A. M., M. !>., 

Lately Professor of Hygiene in the University of Pennsylvania. 
A Conspectus of the Medical Sciences; Containing Handbooks on Anatomy, 
Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics. 
Second edition, thoroughly revised and greatly improved. In one large royal 12mo. 
volume of 1028 pages, with 477 illustrations. Cloth, $4.25; leather, $5.00. 



The work is intended as an aid to the medical 
student, and as such appears to fulfil admirably its 
object by its excellent arrangement, the full com- 

{)ilation of facts, the perspicuity and terseness of 
anguage, and the clear and instructive illustra- 
tions. — American Journal of Pharmacy, J \i\y, 1874. 

The object of this manual is to afford a conven- 
ient work of reference to students during the brief 
moments at their command while in attendance 
upon medical lectures. It is a favorable sign that 
it has been found necessary, in a short space of 
time, to issue a new and carefully revised edition. 
The illustrations are very numerous and unusu- 
ally clear, and each part seems to have received 



its due share of attention. We can conceive such 
a work to be useful, not only to students, but to 
practitioners as well. It reflects credit upon the 
industry and energy of its able editor. — Boston 
Medical and Surgical Journal, Sept. 3, 1874. 

"We can say, with th^ strictest truth, that it is the 
best work of the kind with which we are acquaint- 
ed. It embodies in a condensed form all recent 
contributions to practical medicine, and is there- 
fore useful to every busy pi-actitioner throughout 
our country, besides being admirably adapted to 
the use of students of medicine. The book is 
faithfully and ably executed. — Charleston Medical 
Journal. April, 1875. 



STVnBNTS' SBBIBS OF MAJSTALS. 

A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine 
and Surgery. They will be written by eminent Teachers or Examiners, and will be 
issued in pocket-size 12mo. volumes of 300-540 pages, richly illustrated and at a low price. 
The following volumes may now be announced : Klein's Elements of Histology, Pepper's 
Surgical Pathology, Treves' Surgical Applied Anatomy, Ralfe's Clinical Chemistry, Clarke 
and Lockwood's Dissectors' Manual, and Power's Human -Physiology, (Just ready) ; 
Robertson's Physical Physiology, Bruce's Materia Medica and Therapeutics, Bellamy's 
Operative Surgery, and Bell's Comparative Physiology and Anatomy, {In active preparation 
for early publication.) For separate notices see index on last page. 

NJEILL, JOMW, M. J}., and SMITH, F. G., M. D., 

Late Surgeon to the Penna. Hospital. Prof, of the Institutes of Med. in the Univ. of Penna. 

An Analytical Compendium of the Various Branches of Medical 
Science, for the use and examination of Students. A new edition, revised and improved. 
In one very large royal 12mo. volume of 974 pages, with 374 woodcuts. Cloth, |4; strongly 
bound in leather, raised bands, $4.75. 



Consulting Physician to the Philadelphia Hospital, etc. 
A Manual of Examinations upon Anatomy, Physiology, Surgery, Practice of 
Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and Therapeutics. To which 
is added a Medical Formulary. Third edition, thoroughly revised, and greatly extended 
and enlarged. In one handsome royal 12mo. volume of 816 large pages, with 370 illus- 
trations. Cloth, $3.25 ; leather, |3.75. 

The arrangement of this volume in the form of question and answer renders it espe- 
cially suitable for the office examination of students, and for those preparing for graduation. 

WIZSOJSr, FMASMUS, F. M. S. 

A System of Human Anatomy, General and Special. Edited by W. H. 
Oobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College of 
Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. 
Cloth, $4.00; leather, $5.00. 

SMITH, M. H., M. D., and JELOBWFB, W3I. F.,3I.I>., 

Emeritus Prof, of Surgery in the Univ. of Penna., etc. Late Prof, of Anat. in the Univ. of Penna. 
An Anatomical Atlas, Illustrati\'e of the Structure of the Human Body. In one 
large imperial octavo volume of 200 pages, with 634 beautiful figures. Cloth, ;;^4.50. 

CLBLAJSTD, JOHN, 31. JD^^JK. S., 

Professor of Anatomy and Physiology in Queen'' s College, Gahcay. 

A Directory for the Dissection of the Human Body. In one 12mo, 

volume of 178 pages. Cloth, $1.25. 

BFLLA3IY, FD WAJlIh F. B. ~a~S.7 

Senior Assistant-Surgeon to the Charing-Cross Hospital, London. 

The Student's Guide to Surgical Anatomy: Being a Description of the 
most Important Surgical Kegions of the lluman Body, and intended as an Intr^xluction to 
Operative Surgery. In one i2mo. volume of 300 page's, with 50 illustrations. Cloth, $2.25. 

HARTSIT0RNF;R ITANDROOK of anatomy I ITORNER'SSPECTAL ANATO^fY AND niSTOL- 

ANI) PH\SIOLOGY. Second edition, rovisod. 0(tV. Kia:luh odition. oxtonsivolv revised mid 

In one royal rJnio. volume of ;U0 pai^es^, with '2.-20 nioditiod." In two ootavo volumos"of 1001 pasres 

woodcuts. Cloth, $1.75. "" , I with ;VJO woodcuts. Cloth, St>.iH). 



Henry C. Lea's Son & Co.'s Publications — Anatomy. 



ALLJEW, HAHniSOJS, M. D., 

Professor of Physiology in the University of Pennsylvania. 

A System of Human Anatomy, Including Its Medical and Surgical 
Relations. For the use of Practitioners and Students of Medicine. With an Intro- 
ductory Chapter on Histology. By E. O. Shakespeare, M. D., Ophthalmologist to the 
Philadelphia Hospital. In one large and handsome quarto volume of ahout 700 double- 
columned pages, with 380 illustrations on 109 lithographic plates, many of which are in 
colors, and about 150 engravings in the text. In six Sections, each in a portfolio. Section 
I. Histology {Just ready). Section II. Bones and Joints {Jiisi ready). Section HI. 
Muscles and Fascije {Just ready). Section IV. Arteries, Veins and Lymphatics 
{Ju^t ready). Section V. Nervous System {Just ready). Section VI. Organs of 
Sense, of Digestion and Genito-Urinary Organs {I71 press). Price per Section, 
13.50. For sale by subscription only. Apply to the Publishers 

Extract from Introduction. 

It is the design of this book to present the facts of human anatomy in the manner best 
suited to the requirements of the student and the practitioner of medicine. The author 
believes that such a book is needed, inasmuch as no treatise, as far as he knows, contains, in 
addition to the text descriptive of the subject, a systematic presentation of such anatomical 
facts as can be applied to practice. 

A book which will be at once accurate in statement and concise in terms ; which will be 
an acceptable expression of the present state of the science of anatomy ; which will exclude 
nothing that can be made applicable to the medical art, and which will thus embrace all 
of surgical importance, while omitting nothing of value to clinical medicine, — would appear 
to liave an excuse for existence in a country where most surgeons are general practitioners, 
and where there are few general practitioners who have no interest in surgery. 

Among other matters, the book will be found to contain an elaborate description of the 
tissues ; an account of the normal development of the body ; a section on the nature and 
varieties of monstrosities ; a section on the method of conducting post-mortem examina- 
tions ; and a section on the study of the superficies of the body taken as a guide to the 
position of the deeper structures. These will appear in their appropriate places, duly 
subordinated to the design of presenting a text essentially anatomical. 



A book like this is an ideal rarely realized. It 
is a mine of wealth in the informationit gives. It 
ditiers from all preceding anatomies in its scope, 
and is, we believe, a vast improvement upon them 
all. The chief novelty about the book, and really 
one of the greatest needs in anatomy, is the ex- 
tension of the text to cover not only anatomical 
descriptions, but the uses of anatomy in studying 
disease. This is done by stating the narrov^er 
topographical relations, and also the wider clin- 
icaj, relations, of the more remote parts, by giving 
a brief account of the uses of the various organs, 
and by quoting eases which illustrate the "local- 
ization of diseased action." The plates are beau- 
tiful specimens of work by one who long since 
won a deserved reputation as an artist. — The Medi- 
cal Keivs, October 21, 1882. 

The appearance of the book marks an epoch in 
medical literature. It is the first important work 
on human anatomy that has appeared in America; 
and, more than this, its scope is new and original, 
it is intended to be both descriptive and topograph- 
ical, scientific and practical, so that while satisfy- 
ing the anatomist it will be of value to the practis- 
ing physician. The names of the parts, muscular 
attachments, etc., are printed either on the figure 
or close beside, so that they are easily recognized. 
The illustrations made from the author's dissec- 
tions deserve the highest praise. They are well con- 
ceived and well executed, handsome artistically 
and clear anatomically. As the author points out, 
■ such a work as he has undertaken is necessarily 
encyclopaedic, and the result shows that he has 



brought to it a mind well prepared for the task by 
extensive reading, critical judgment and literary 
ability. We can cordially recommend the work 
to the profession, believing that it is suited not 
only to those of scientific tastes, but that it will be 
of use to the practising physician. — Boston Medical 
and Surgical Journal, Jan. 11, 1883. 

It is to be considered a study of applied anatomy 
in its widest sense — a systematic presentation of 
such anatomical facts as can be applied to the 
practice of medicine as well as of surgery. Our 
author is concise, accurate and practical in his 
statements, and succeeds admirably in infusing 
an interest into the study of what is generally con- 
sidered a dry subject. The department of Histol- 
ogy is treated in a masterly manner, and the 
ground is travelled over by one thoroughly famil- 
iar with it. The illustrations are made with great 
care, and are simply superb. It would be impos- 
sible, except in a general way, to point out the 
excellence of the work of the author in the second 
Section — that devoted to the consideration of the 
Bones and Joints. There is as much of practical 
application of anatomical points to the every-day 
wants of the medical clinician as to those of the 
operating surgeon. In fact, few general practi- 
tioners will read the work without a feeling of sur- 
prised gratification that so many points, concern- 
ing which they may never have thought before, 
are so well presented for their consideration. It 
is a work which is destined to be the best of its 
kind in any language. — Medical Record, Nov. 25, '82. 



CLAMKJE, W. B., F.It. C.S. & LOCKWOOD, C. B., F.B. C.S. 

Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. 

The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 
49 illustrations. Limp cloth, red edges, $1.50. Just ready. See Student^ Series of 
Manuals, page 5. 



This is a very excellent manual for the use of the 
student who desires to learn anatomy. The meth- 
ods of demonstration seem to us very satisfactory. 
There are many woodcuts which, for the most 



part, are good and instructive. The book is neat 
and convenient. We are glad to recommend it. — 
Boston Medical and Surgical Journal, Jan. 17, 1884. 



TBBVJES, FBEDBBICK, F. M. C. S., 

Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital. 
Applied Anatomy. In one pocket-size 12mo. volume of 540 pages, with 61 illus- 
trations. Limp cloth, red edges, $2.00. Just ready. See Students' Series of Manuals, page 5. 
He has produced a work which will command a I quickened by daily use as a teacher and practi- 
Jarger circle of readers than the class for which it tiouer, has enabled our author to prepare a work 
was written. This union of a thorough, practical which^it would be a most diflftcult task to excel. — 
acquaintance with these fundamental branches, | The American Practitioner, Feb., 1884. 



Henry C. Lea's Son & Co.'s Publications — Anatomy. 7 

GRAY, HBNMY, F. M. S., 

Lecturer on Anatomy at St. George's Hospital, London. 

Anatomy, Descriptive and Surgical. The Drawings by H. V. Carter, M. D., 
and Dr. Westmacott. The dissections jointly by the Author and Dr. Carter. With 
an Introduction on General Anatomy and Development by T. Holmes, M. A., Surgeon lo 
St. George's Hospital. Edited by T. Pickering Pick, F. P. C. S., Surgeon and Lecturer 
on Anatomy at St. George's Hospital, London, Examiner in Anatomy, Eoyal College of 
Surgeons of England. A new American from the tenth enlarged and improved London 
edition. To which is added the second American from the latest English edition of 
Landmarks, Medical and Surgical, by Luther Holden, F. E. C. S., author of 
" Human Osteology," " A Manual of Dissections," etc. In one imperial octavo volume 
of 1023 pages, with 564 large and elaborate engravings on wood. Cloth, $6.00 ; leather, 
$7.00 ; very handsome half Russia, raised bands, $7.50. Just ready. 

This work covers a more extended range of subjects than is customary in the ordinary 
text-books, giving not only the details necessary for the student, but also the application of 
those details to the practice of medicine and surgery. It thus forms both a guide for the 
learner and an admirable work of reference for the active practitioner. The engravings 
form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in 
place of figures of reference with descriptions at the foot. They thus form a complete and 
splendid series, which will greatly assist the student in forming a clear idea of Anatomy, 
and will also serve to refresh the memory of those who may find in the exigencies of 
practice the necessity of recalling the details of the dissecting-room. Combining, as it 
does, a complete Atlas of Anatomy with a thorough treatise on systematic, descriptive 
and applied Anatomy, the work will be found of great service to all physicians who receive 
students in their offices, relieving both preceptor and pupil of much labor in laying the 
groundwork of a thorough medical education. 

Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden, 
has been appended to the present edition as it was to the previous one. This work gives 
in a clear, condensed and systematic way all the information by which the practitioner can 
determine from the external surface of the body the position of internal parts. Thus 
complete, the work, it is believed, will furnish all the assistance that can be rendered by 
type and illustration in anatomical study. 

There is probably no work used so universally 
by physicians and medical students as this one. 
It is deserving of the confidence that they repose 
in it. If the present edition is compared with that 
issued two years ago, one will readily see how 
much it has been improved in that time. Many 
pages have been added to the text, especially in 
those parts that treat of histology, and many new 
cuts have been introduced and old ones modified. 
— Journal of the American Medical Association, Sept. 
1, 18S3. 



This well-known work comes to us as the latest 
American from the tenth English edition. As its 
title indicates, it has passed through many hands 
and has received many additions and revisions. 
The work is not susceptible of more improvement. 
Taking it all in all, its size, manner of make-up, 
its character and illustrations, its general accur- 
acy of description, its practical aim, and its per- 
spicuity of style, it is the Anatomy best adapted to 
the wants of the student and practitioner. — Medical 
Record, Sept. 15, 1883. 



Also for sale separate — 
MOLJDBW, LJJTMBB, F. M. C. S., 

Surgeon to St. Bartholomew's and the Foundling Hospitals, London. 
Landmarks, Medical and Surgical. Second American from the latest revised 
English edition, with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in 
the Pennsylvania Academy of the Fine Arts, formerly Lecturer on Anatomy in the Phila- 
delphia School of Anatomy. In one handsome 12mo. volume of 148 pages. Cloth, |1.00. 

This little book is all that can be desired within 
its scope, and its contents will be found simply in- 
valuable to the young surgeon or physician, s'ince 
they bring before him such data as he requires at 
every examination of a patient. It is written in 
language so clear and concise that one ought 



almost to learn it by heart. It teaches diagnosis by 
external examination, ocular and palpable, of the 
body, with such anatomical and physiological facts 
as directly bear on the subject, tt is eminently 
the student's and young practitioner's book. — Phy- 
sician and Surgeon, Nov. ISSl. 



DALTOJSr, JOJBLW a, Im. D., 

Professor of Physiology in the College of Physicians and Surgeons, New York. 

The Topographical Anatomy of the Brain. In one very handsome quarto 
volume of about 200 pages of descriptive text. Illustrated with forty-nine life-size photo- 
graphic illustrations of Brain Sections, with a like number of outline explanatory plates, 
ai well as many carefully-executed woodcuts through the text. In pre^s. 

ELLIS, GFOBGF VIWBJR, ^ 

Emeritus Professor of Anatomy in University College, London. 

Demonstrations of Anatomy. Being a Guide to the Knowledge of the 
Human Body by Dissection. From the eighth and revised London edition. In one vorv 
handsome octavo volume of 71G pages, with" 249 illustrations. Cloth, S4.2o ; leather, $rx2i 
Ellis' Dernonstratioiis is the favorite text-book special line. The doscriynious are oloat, and the 
of tlie Kuglislv stiidout of anatomy. In passing metliods of pursuina; auatoiuioal investigations are 
Uirough eight editions it has been so revised auii u;iven with such detail that tlie book is honestlv 
adapted to the needs of the student that it would entitled to its namo.— ^V. Louis Clinical Rt.cor,), 
seem that it had almost reached perfection in this June, ISTi). 



8 



Henry C. Lea's Son & Co.'s Publications— Physiology. 



DALTOJ^, JOSJS^ C, M. JD., 

Professor of Physiology in the College of Physicians and Surgeons, Kew York, etc. 

A Treatise on Human Physiology. Designed for the use of Students and 
Practitioners of Medicine. Seventh edition, thoroughly revised and rewritten. In one 
very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth, 
$5.00 ; leather, §6.00 ; very handsome half Eussia, raised bands, $6.50. 

previous one, and will tend to keep the profession 
posted as to the most recent additions to our 
physiological knowledge. — Michigan Medical News, 
April, 1882. 
One can scarcely open a college catalogue that 



The merits of Professor Dalton's text-book, his 
smooth and pleasing style, the remarkable clear- 
ness of his descriptions, which leave not a chapter 
obscure, his cautious judgment and the general 
correctness of his facts, are perfectly known. They 
have made his text-book the one most familiar 
to American students. — Med. i?eco?-c?, March 4, 1882. 



does not have mention of Dalton's Physiology as 
the recommended text or consultation-Book. For 



Certainh' no phj'siological work has ever issued j American students we would unreservedly recom- 
from the press that presented its subject-matter in : mend the edition of Dr. Dalton's work now before 
a clearer and more attractive light. Almost every us. Let it suffice to state that revisions have been 
page bears evidence of the exhaustive revision ; made to such an extent as to bring the volume as 
hat has taken place. The material is placed in a : fullyup to the present state of physiological knowl- 
more compact form, yet its delightful charm is re- \ edge as it is practicable for am' author of a book 
tained, and no subje'^ct is thrown into obscurit}'-. j to do. — Virginia Medical Monthly, July, 1S82. 
Altogether this edition is far in advance of anj' , 

FOSTJEB, MICHAEL, 31. JD., F. B. S., 

Professor of Physiology in Cambridge University, England. 

Text-Book of Physiology. Second American from the third English edition. 

Edited, with extensive notes and additions, by Edward T. Keichert, M. D., late 

Demonstrator of Experimental Therapeutics in the University of Pennsylvania. In one 

handsome royal 12mo. volume of 999 pages, with 259 illusl. Cloth, $3.25 ; leather, $3.75. 

A more compact and scientific work on physiol- | Dr. Michael Foster's Manual of Physiology has 
ogy has never been published, and we believe our- i been translated into the German, with a preface, 
selves not to be mistaken in asserting that it has ' by Professor Kiihne. Kiihne points out in his 
very medical college j preface that the abundant material, in spite of the 
"'' '' moderate size, is not condensed to systematic 



now been introduced into 

in which the English language is spoken. This 
work conforms to the latest researches into zoology 
and comparative anatomy, and takes into consid- 
eration the late discoveries in physiological chem- 
istry and the experiments in localization of Ferrier 
and others. The arrangement followed is such as 
to render the whole subject lucid and well con- 
nected in its various parts. — Chicago Medical Jour- 
nal and Examiner, August, 1882. 



shortness, but the whole is related in a narrative 
style. The translation of it into German is a well- 
merited compliment, since Germany is the es- 
pecial home of physiology, and its literature is 
abundantly rich in text-books, monographs and 
periodicals on phj^siology. — American Medical Bi- 
Weekly, June 18, 1881. 



POWJEM, SLBWBY, 31. B., F. B. C. S., 

Examiner in Physiology, Royal College of Surgeons of England. 
Human Physiology. In one handsome pocket-size 12mo. volume of 396 pages, 
with 47 illustrations. Cloth, 81.50. Just ready. See Students^ Series of Manuals, page 5. 

This little work is deserving of the highest 
praise, and we can hardly conceive how the main 
facts of this science could have been more clearlj' 
or conciselj' stated. The price of the work is such 



as to place it within the reach of all, while the ex- 
cellence of its text will certainly secure for it most 
favorable commendation. — Cincinnati Lancet and 
Clinic, Feb. 16, 1884. 



BOBFBTSON, J. 3IcGBEGOB, 31. A., 31. B., 

Muirhead Demonstrator of Physiology, University of Glasgoiv. 
Physical Physiology. In active preparation. See Students^ Series of Manuals, page 5. 

BELL, F. JEFFBEY, 3L A., 

Professor of Comparative Anatomy at King's College, London. 

Comparative Physiology and Anatomy. In active preparation for early 
publication. See Students' Series of 3Ianuals, page 5. 

CABFEJSTTEB, W3I. B., 3L D., F. B. S., F. G. S., F. L. S., 

Registrar to the University of London, etc. 

Principles of Human Physiology. Edited by Hexhy Power, M. B., Lond., 
F, E. C. S., Examiner in Natural Sciences, University of Oxford. A new American from the 
eighth revised and enlarged edition, with notes and additions by Feaxcis G. Smith, M. D., 
late Professor of the Institutes of Medicine in the University of Pennsylvania. In one 
very large and handsome octavo volume of 1083 pages, with two plates and 373 illus- 
trations Cloth, $5.50 ; leather, $6.50 ; half Eussia, $7. 
The editors have, with their additions to the tion. We have been agreeablj' surprised to find 

the volume so complete in regard to the structure 
and functions of the nervous system in all its rela- 
tions — a subject that in many respects is one of 
the most difficult of all, in the whole range of 
physiology, upon which to produce a full and satis- 
factory treatise of the class to which the one be- 
fore us belongs. — Jl. ofNerv. and Ment. Bis., Apr.,'77. 



only work on physiologj'- in our language that, in 
the fullest sense'of the word, is the production of 
a philosopher as well as a physiologist, brought it 
up fully to the standard of our knowledge of its 
subject at the present day. The additions bj' the 
American editor give to the work as it is a consid- 
erable value beyond that of the last English edi- 



CARPENTER'S PRIZE ESSAY ON THE USE AND 
Abuse of Alcoholic Liquoks in Health and Dis- 
ease. With a preface by D. F. Condie, M. D., and 
explanations of scientific words. In one small 
12DQ0. volume of 178 pages. Cloth, 60 cents. 



LEHMANN'S MANUAL OF CHEMICAL PHYS- 
IOLOGY. Translated from the German with 
notes and additions, by J. Cheston IMoreis, M. D. 
In one octavo volume'of 327 pages, with 41 illus- 
trations. Cloth, §2.25. 



Henry C. Lea's Son & Co.'s Publications — Chemistry. 



ATTFIJELJD, JOHN, I'll. D., 

Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc. 

Chemistry, General, Medical and Pharmaceutical; Including the Chem- 
istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, 
and their Application to Medicine and Pharmacy. A new American, from the tenth 
English edition, specially revised by the Autiior. In one handsome royal 12mo. volume 
of 728 pages, with 87 illustrations. Cloth, |2.50 ; leather, $3.00. Just ready. 



It is a book on which too much praise cannot be 
bestowed. As a text book for medical schools it 
is unsurpassable in the present state of clinical 
science, and having been prepared with a special 
view towards medicine and pharmacy, it is alilie 
indispensable to all persons engaged in those de- 
partments of science. It includes the whole 
cliemistry of the last Pharmacopoeia. — Pacific Medi- 
cal and Surgical Journal, Jan. 1884. 



The clearness, system and thoroughness of this 
manual have made 'it for the last sixteen years the 
constant companion of the medical and pharma- 
ceutical student. Within this time it has under- 
gone ten editions, which have progressively en- 
larged its scope and general usefulness. We again 
welcome the book, and give it a cordial endorse- 
ment. — New Orleans Medical and Surgical Journal , 
January, 1884. 



BLOXAM, CMAMLES X., 

Professor of Chemistry in King's College, London. 

Chemistry, Inorganic and Organic. New American from the fifth Lon- 
don edition, thoroughlv revised and much improved. In one very handsome octavo 
volume of 727 pages, with 292 illustrations. Cloth, $3.75 ; leather, $4.75. Just ready. 



The general plan of this worlc remains the 
same as in previous editions, the evident object 
being to give clear and concise descriptions of all 
known elements and of their most important 
compounds, with explanations of the chemical 
laws and principles involved. We gladly i-epeat 
now the opinion we expressed about a former 
edition, that we regard Bloxam's Chemistry as 
one of the best treatises on general and applied 
chemistry. — American Jour, oj Pharmaci/, Dec. 1883. 

Comment from us on this standard work is almost 
superflaons. It differs widely in scope and aim 
from tiiat of Atlfield, and in its way is equally 
beyond criticism. It adopts the most "direct meth- 
ods in stating the principles, hypotheses and facts 
of the science. Its laaguage is so terse and lucid, 
and its arrangement of matter so logical in se- 



quence, that the student never has occasion to 
complain that chemisti-y is a hard study. Much 
attention is paid in this work to experimental 
illustrations of chemical principles and phenom- 
ena, and the mode of conducting these experi- 
ments. The book maintains the position it has 
always held as one of the best manuals of general 
chemistry in the English language. — The Detroit 
Lancet, February, 1884. 

This ample and thorough treatise on chemistry 
has in this revision been extended and brought 
down to the latest date, so as to include a notice of 
all important recent discoveries in this progressive 
science. In this edition the theoretical portions 
have received especial attention, so as to bring 
them into accordance with modern views. — Med. 
and Surgical Reporter, Dec. 1, 1883. 



nE3ISMW, IMA, M. D., JPh. D., 

Professor of Chemistry in the Johns Hopkins University, Baltimore. 

Principles of Theoretical Chemistry, with special reference to the Constitu- 
tion of Chemical Compounds, Second and revised edition. In one handsome royal 12mo. 
volume of 240 pages. Cloth, $1.75. Just ready. 



The book is a valuable contribution to the chemi- 
cal literature of instruction. That in so few years 
a second edition has been called for indicates that 
many chemical teachers have been found ready 
to endorse its plan and to adopt its methods. In 
this edition a considerable proportion of the bool?: 
has been rewritten, much new matter has been 
added and the whole has been brought up to date. 
We earnestly commend this book to every student 
of chemistry. The high reputation of the author 
assures its accuracy in all matters of fact, and its 
judicious conservatism in matters of theory, com- 
Dined with the fulness with which, in a small 
compass, the present attitude of chemical science 
towards the constitution of compounds is con- 
sidered, gives it a value much beyond that accorded 



to the average text books of the day. — American 
Journal of Science, March, 1884. 

We would heartily recommend it to any student 
who desires to acquaint himself with the subject. 
In the matter we can find nothing to criticise. 
Every point is explained with perfect satisfaction, 
so that the merest tyro may understand. — Physician 
and Surgeon, Dec. 1883. 

When the first edition made its appearance, we 
welcomed it as a very valuable addition to litera- 
ture; the more we have consulted it since that 
time the more we have appreciated its value. The 
book deserves to be placed in the hands of every 
student of chemistry. — Ainerican Journal of Phar- 
rnacy, December, 1883. 



FOWJSrJES, GEOItGB, JPh. JO. 

A Manual of Elementary Chemistry; Theoretical and Practical. Eevised 
and corrected by Henry Watts, B. A., F. R. S., Editor of A Dictionary of Chemistry, 
etc. A new American from the twelfth and enlarged London edition. Edited by Koi^ert 
Bridges, M. D. In one large royal 12mo. volume of 1031 pages, with 177 illustrations 
on wood and a colored plate. Cloth, $2.75 ; leather, $3.25. 

The book opens with a treatise on Chemical 
Physics, including Heat, Light, Magnetism and 
Electricity. 'J'hese subjects are treated clearly 
and briefly, but enough is given to enal)le the stu- 
dent to comprehend the facts and laws of Chemis- 
try proper. It is the fashion of late years to omit 
these topics from works on chemistry, but their 
omission is not to be commended. .\s was required 
by the groat advance in the science of Chemistry 



of late years, the chapter on the General Principles 
of Chemical Philosophy has been entirely rewrit- 
ten. The latest views on Kquivalents, Quantiva- 
lence, etc., are clearly and fully set forth. This 
last edition is a great improvement upon its prede- 
cessors, which is saying not a little of a book th.<»t 
has reached its twelfth edition. — Ohio Moiiical R&- 
eorder, Oct., 187S. 



Wohler's Outlines of Organic Chemistry. Edited by Fittig. 
by Ira Remsen, M. D., Ph. D. In one 12mo. volume of 550 pages. Cloth, ^c 



Translated 



10 



Henry C. Lea's Son & Co.'s Publications — Chemistry. 



HOFFMAJSnsr, F., A.M., JPh.JD., & FOWFIt F.B., Fh.D., 

Public Analyst to the State of New York. Prof, of Anal. Chtm. Phil. Coll. of Pharmacy. 

A Manual of Chemical Analysis, as applied to the Examination of Medicinal 
Chemicals and their Preparations, Being a Guide for the Determinr. ion of their Identity 
and Quality, and for the Detection of Impurities and Adulterat* ms. For the use of 
Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and 
Medical Students. Third edition, entirely rewritten and much enlarged. In one very 
handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 



We congratulate the author on the appearance 
of the third edition of this work, published for the 
first time in this country also. It is admirable and 
the information it iindertakes to supply is both 
extensive and trustworthy. The selection of pro- 
cesses for determining the purity of the substan- 
ces of which it treats is excellent and tne descrip- 
tion of them singularly explicit. Moreover, it is 
exceptionally free from typographical errors. We 
have no hesitation in recommending it to those 
who are engaged either in the manufacture or the 
testing of medicinal chemicals. — London Pharma- 
ceutical Journal and Transactions, 1883. 

Viewed in regard to its general aims as well as 
to the manner in which thej' have been carried 
out, the work will be found as complete as can well 
be desired. The descriptions of operations are 



full without being redundant, so that the tyro can 
easily understana them and practise the processes 
successfully. The work is thus well adapted as a 
book of reference for practical use, and calculated 
to impart such information as in each particular 
case may be usefitl or required within the limit of 
its objects. — American Journal of Phar., May, 1883. 
This work has undergone a very considerable 
change since the first edition appeared in 1873; 
in its present form it is a marked improvement 
on the earlier editions. The authors are to be 
congratulated on the manner in which they have 
remodelled the work ; in its present form it is 
sure to prove a valuable aid in the practice of 
pharmaceutical chemistry. — Lond. Chemist, and 
Druggist, Jtme 15, 1883. 



WATTS, HFWBY, B. A., F. B. S, 

Author of "J. Dictionary of Chemistry," etc. 

A Manual of Physical and Inorganic Chemistry. 

of 500 pages with 150 illustrations. In press. 



In one 12mo. volume 



CLOWFS, FBAJVB:, jy. Sc, London, 

Senior Science-Master at the High School, JVewcastle-under-Lyme, etc. 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 
Colleges and by Beginners. Second American from the third and revised English edition. 



In one very handsome royal 12mo. volume of 372 pages, with 47 illustrations. Cloth, ^2.50. 

The chief object of the author of the present work 
was to furnish one which was sufficiently elemen- 
tary in the description of apparatuses, chemicals, 
modes of experimentation, etc., so as to "reduce 
to a minimum the amount of assistance required 
from a teacher." It is a generally recognized fact 
that one of the most serious hindrances to the 
utility of many of the smaller text-books is the too 
great conciseness of the language employed, which 



renders it unintelligible to the primary student 
unless supplemented by copious verbal explana- 
tions from the teacher. The Elementary Treatise 
of Dr. Clowes, examined with reference to the 
above claims, is found to be a great improvement 
on other elementary works. A student who care- 
fully reads this text will scarcely need the assist- 
ance of a tutor in following out any of the ex- 
periments described. — Va. Med. 3Ionthly,Ai>.,lS81. 



BALFF, CHABLFS JET., M. !>., F. B. C. F., 

Assistant Physician at the London Hospital. 
Clinical Chemistry. In one pocket-size 12mo. volume of 314 pages, with 16 

See Students' Series of Manuals, page 5. 
cine. Dr. Ralfe is thoroughly acquainted with the 
latest contributions to his science, and it is quite 
refreshing to find the subject dealt with so clearly 
and simply, yet in such evident harmony with the 
modern scientific methods and spirit. — Medical 
Record, February 2, 1884. 



illustrations. Limp cloth, red edges, §1.50 
This is one of the most instructive little works 
that we have met with in a long time. The author 
is a physician and physiologist, as well as a chem- 
ist, consequently the" book is unqualifiedly prac- 
tical, telling the physician just what he ought to 
know, of the applications of chemistry in medi- 



CLASSFW, ALFXAWnFB, 

Professor in the Royal Polytechnic School, Aix-la-Chapelle. 
Elementary Quantitative Analysis. Translated, Avith notes and additions, by 
Edgak F. Smith, Ph. D., Assistant Professor of Chemistry in the Towne Scientific School, 
University of Pennsylvania. In one handsome royal 12mo. volume of 324 pages, with 36 
illustrations. Cloth, $2.00. 

It is probably the best manual of an elementary j and then advancing to the analysis of minerals and 
natitre extant, insomuch as its methods are the ; such products as are met with in applied ehemis- 
best. It teaches by examples, commencing with ' try. It is an indispensable book for students in 
single determinations, followed by separations, ; chemistry. — Boston Journal of Chemistry, Oct. 1878. 



GBFFNF, WILLIAM H., 31. D., 

Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania. 

A Manual of Medical Chemistry. For the use of Students. Based upon Bow- 
man's Medical Chemistry. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. 
It is a concise manual of three hundred pages, ] the recognition of compounds due to pathological 
giving an excellent summary of the best methods 
of analyzing the liquids and solids of the body, both 



for the estimation of their normal constituents and 



conditions. The detection of poisons is treated 
with sufficient fulness for the purpose of the stu- 
dent or practitioner. — Boston Jl. of Chem., June, '80. 



A MANUAL OF QUALITATIVE ANALYSIS. 
By Robert Galloway, F. C. S. From the sixth 



Loudon edition. In one royal 12mo. volume, with 
illustrations. Preparing. 



Henry C. Lea's Son & Co.'s Publications — Pharm., Mat. Med. U 
BABMISH, JED W Ann, 

Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy. 
A Treatise on Pharmacy : designed as a Text-book for the Student, and as a 
Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. 
Fifth edition, thoroughly revised, by Thomas S. Wiegand, Ph. G. In one handsome 
octavo volume of 1093 pages, with 256 illustrations. Cloth, $5 ; leather, $6. Just ready. 
From the Preface to the Fifth Edition. 
A new edition of Mr. Parrish's standard work has been rendered an imperative necessity, 
not only by the late revision of the U. S. Pharmacopoeia, but also by the great advance in 
chemical and pharmaceutical science within the last decade. The changes thus required 
have rendered the task of the editor by no means light, and have considerably increased 
the size of the volume, in spite of earnest efforts at condensation and the omission of all 
obsolete matter. The new preparations of the Pharmacopoeia have been introduced, to- 
gether with its tests for chemical and officinal compounds, and its system of parts by weight 
in place of definite quantities. The entire chemical section has been rearranged in con- 
formity with the present views of that science, and the subject of testing, both qualitative 
and quantitative, has been rendered as complete as the scope of the work would permit and 
the wants of students are likely to require. All general pharmaceutical and chemical pro- 
cesses have been arranged in a separate part, thus facilitating reference and avoiding 
repetition, while special apparatus for particular classes of preparations has been placed 
under those classes. The syllabi, which proved so valuable a feature of previous editions, 
and on which Professor Maisch bestowed so much care, have been retained ; many of th em 
have been rewritten and new ones introduced. All new remedies of interest have been 
added, and in the chapter on elixirs some new formulae of much popularity have been 
given. The editor need only add that he has spared no labor or care in the hope of ren- 
dering the work as acceptable as it has hitherto been to the student and the pharmaceutist. 

This well-known work presents itself now based 
upon the recently revised new Pharmacopoeia. 
Several important modifications of the internal 
arrangement have been made, and we believe 
they will be found to increase the practical use- 
fulness of the book. Each page bears evidence of 
the care bestowed upon it, and conveys valuable 
information from the rich store of the editor's 



experience. In fact, all that relates to practical 
pharmacy — apparatus, processes and dispensing — 
has been arranged and described with clearness 
in its various aspects, so as to afford aid and advice 
alike to the student and to the practical pharma- 
cist. The work is judiciously illustrated with good 
woodcuts — American Journal of Pharmacy, Janu- 
ary, 1884. 



HJEMMAWW, Dr. L., 

Professor of Physiology in the University of Zurich. 
Experimental PharrQacology. A Handbook of Methods for Determining the 
Physiological Actions of Drugs. Translated, with the Author's permission, and with 
extensive additions, by Kobert Meade Smith, M. D., Demonstrator of Physiology in the 
University of Pennsylvania. In one handsome 12mo. volume of 199 pages, with 32 
illustrations. Cloth, $1.50. Just ready. 



The selection of animals and their management, 
the paths of elimination and changes of poisons 
in the body, the explanation of the symptoms pro- 
duced by poisons, alterations in tissue, in the re- 
productive function and in temperature, action on 
muscles and in nerves, anatomical and chemical 
changes produced by poisons, all are successively 
passed in review in a practical instructive fashion, 
which speaks well for both the author and the 
translator. The book is deserving of an enco- 
mium as a correct exponent of the spirit and 
tendencies of modern pharmacological research. 



After closely perusing the pages, all laden to over- 
flowing with the richest facts of physiological in- 
vestigation, and after following the astounding 
progress of toxic pharmacology as revealed by the 
author, we feel that we are fast approaching the 
realization of that Utopian dream in which we 
behold experimental and clinical experience 
firmly and inseparably united. It is a reliable, 
concise and practieart'rtdc mecum for the time- 
pressed worker in the laboratory. — Neiv Orleans 
Medical and Surgical Juurtial, May, 1883. 



MAISCH, JOHJSril., riiar. JD., 

Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. 

A Manual of Organic Materia Medica; Being a Guide to Materia Medica of 
the Vegetable and Animal Kingdoms. For the use of Students, Di'uggists, Pliarmacists 
and Physicians. New edition. In one Jiandsome royal 12mo. volume. Preparing. 
A few notices of the previous edition are appended. 

A book evidently written for a purpose, and not 
simply for the purpose of writing a book. It is 
comprehensive, as it refers to all, or nearly all, 
that is of essential value in organic materia medica. 



clear and simple in its style, concise, since it would 
be difficult to find in it a suporfinous word, and yet 
sufiiciently explicit to satisfy the most critical. — 
Chicago 3'Icd. Jul. and Exam., .^.ug. 1S82. 



D UJAniyiW-BBA IJMBTZ, 

Member of the Academy of Medicine, Physician to the Ihlpifal St. Antoine, Paris. 

Dictionary of Therapeutics, Materia Medica, Pharmacology, Tox- 
icology and Mineral Waters. Translated with notes and additions. Preparing. 

GIIIFFITH, 1WB]EBt1e(^.]^FTEZI>, M. Jh 

A Universal Formulary, containing the INIethods of Preparing and Adminis- 
tering Oliicinalaiid other l^lcdicines. The whole adapted to rhysici:ins and Ph;\rn\;u\nit- 
ists. Tliird edition, thoroughly revised, witli numovous additions, by John M. Maisch, 
Phar.D., Professor of Materia Medica and l>otany in the Philadol[)hia College of Pharmacy. 
In one octavo volume of 775 pages, with 38 illustrations. Cloth, $4.50 ; leuth er, $5.50. 



12 Henry C. Lea's Son & Co.'s Publications — Mat. Med., Therap. 
STILLB, A., 31. D., LL. n., & MAISCS, J. 3£.,JP7iar.D., 

Professor of the Theory and Practice of Prof of Mat. Med. and Botany in Phila. 

Medicine and of Clinical Medicine in the College of Pharmacy/, Sec' i/ to the Amerir 

University of Pennsylcania. can Pharmaceutical Association. 

The National Dispensatory : Containing tlie Natural History, Chemistry, Phar- 
macy, Actions and Uses of Medicines, including those recognized in the Pharmacopoeias of 
the United States, Great Britain and Germany, with numerous references to the French 
Codex. Third edition, thoroughly revised and greatly enlarged. In one magnificent 
imperial octavo volume of about 1800 pages, with several hundred fine engravings. In press. 

The publishers have much pleasure in announcing to the Medical and Pharmaceutical 
Professions that a new edition of this important work is in press, and that it will appear 
in the shortest time consistent with the care requisite for printing a work of immense 
detail, where absolute accuracy is of such supreme importance. Besides its revision on 
the basis of the IT. S. Pharmacopoeia of 1880, it will include all the advances made in its 
department during the period elai:)sed since the preparation of that work. To this end all 
recent medical and pharmaceutical literature, both domestic and foreign, has been thor- 
oughly sifted, and everything that is new and important has been introduced, together 
with the results of original investigations. To accord with the new Pharmacopoeia the 
officinal formula are given in parts by weight, but in every instance, for the sake of con- 
venience, the same proportions are also expressed in ordinary weights and measures. The 
Therapeutical Index has been enlarged so that it contains about 8000 references, arranged 
under an alphabetical list of diseases, thus placing at the disposal of the practitioner, in the 
most convenient manner, the vast stores of therapeutical knowledge constantly needed in 
his daily practice. The work may therefore be justly regarded as a complete Encyclo- 
paedia of Materia Medica and Therapeutics, including 1883. 

The exhaustion of two very large editions of The ISTatioxai. Dispexsatory since 
1879 is the most conclusive testimony as to the necessity which demanded its preparation 
and to the admirable manner in which that duty has been performed. In this revision 
the authors have sought to add to its usefulness by including everything properly coming 
within its scope which can be of use to the physician or pharmacist and at the same time 
by the utmost conciseness and by the omission of all obsolete matter to prevent undue 
increase in the size of the volume. No care will be spared by the publishers to render 
its typograjDhical execution worthy of its wide reputation and universal use as the 
tandard authority. 

FABQUSABSO^^, JROBMBT, 31. J)., 

Lecturer on Materia Medica at St. Mary's Hospital Medical School. 

A Guide to Therapeutics and Materia Medica. Third American edition, 
specially revised by the Author. Enlarged and adapted to the U. S. Pharmacopoeia by 
Fea2sK Woodbury, M. D. In one handsome 12mo. volume of 524 pages. Cloth, |2.25. 

Dr. Farquharson's Therapeutics is constructed \ the disease in which observers (who are nearly al- 
upon a plan which brings before the reader all the j ways mentioned) have obtained from it good re- 
essential points with reference to the properties of i suits — make a very good arrangement. The early 
drugs. It impresses these upon him in such away ' chapter containing rules for prescribing is excel- 
as to enable him to take a clear view of the actions ; lent. We have much pleasure in once more draw- 
of medicines and the disordered conditions in i ing attention to this valuable and well-digested 
which they must prove useful. The double-col- ! book, and predict for it a continued successful ca- 
umned pages — one side containing the recognized | reer. — Canada Med. and Surg. Journal, Dec. 1882. 
physiological action of the medicine, and the other | 



BBUJSrTOJS, T. LAUDEB, 31. D., 

Lecturer on Materia Medica and Therapeutics at St. Bartholomew's Hospital, etc. 

A Mianual of Materia Medica and Therapeutics, including the Pharmacy, 

the Physiological Action and the Therapeutical Uses of Drugs. In one handsome octavo 
volume. In press. 

BBUCE, J. 31ITCBLBLL, 31. X>., F. B. C. P. 

Materia Medica and Therapeutics. In active preparation for early publication. 
See Students' Series of Manuals, page 5. 



STILLB, ALFBEJD, 31. D., LL. 2>., 

Professor of Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. 

Therapeutics and Materia Medica. A Systematic Treatise on the Action and 
Uses of Medicinal Agents, including their Description and History. Fourth edition, 
revised and enlarged. In tAvo large and handsome octavo volumes, containing 1936 pages. 
Cloth, $10.00 ; leather, $12.00 ; very handsome half Kussia, raised bands, $13.00. 

The rapid exhaustion of three editions and the ! multitude of its citations and the fulness of its 
universal favor with which the work has been re- ! research into clinical histories, and we must assign 
ceived by the medical profession are sufficient j it a place in the pliysician's libraiy; not, indeed, 
proof of its excellence as a repertory of practical • as fullv representing the present state of knowledge 
and useful information for the phvsician. The ' ■ ■ ' - . , , „ , 



edition before us fully sustains this verdict. — 
ArneiHcan Journal of Pharmacy, Feb. 1875. 
We can hardly admit that it has a rival in the 



in pharmacodynamics, but as by far the most com- 
plete treatise iipon the clinical and practical side 
of the question. — Boston Medical and Surgical Jour- 
nal, Nov. 5, 1874. 



Henry C. Lea's Son & Co.'s Publications — Therap., Pathol., Histol. 13 



COATS, JOSJEJPM, 31. JD., F. 

Pathologist to the Glasgoio Western Infirmary. 

A Treatise on Pathology. In one 

^th 339 beautiful illustrations. Cloth, $5.50 

The work before ns treats the subject of Path- 
ology more extensively than it is usually treated 
in similar works. Medical students as well as 
physicians, who desire a work for study or refer- 
ence, that treats the subjects in the various de- 
partments in a very thorough manner, but without 
prolixity, will certainly give this one the prefer- 
ence to any with which we are acquainted. It sets 
forth the most recent discoveries, exhibits, in an 
interesting manner, the changes from a normal 



F. JP. S., 

very handsome octavo volume of '829 pages, 
; leather, $6.50. Just ready. 
condition effected in structures by disease, 'and 
points out the charaeteri^tics of various moabid 
agencies, fio that they can be easily recognized. P*ut, 
not limited to morbid anatomy,it explains fully how 
the functions of organs are disturbed Viy abnorm.al 
conditions. There is nothing belonging to its de, 
partmentof medicine that is notasfully elucidated 
as our present knowledge will admit. — Cincinnati 
Medical News, Oct. 1883. 



WOODMEAD, G. SIMS, 31. D., F. B. €. r. F., 

Demonstrator of Pathology in the University of Edinburgh. 



Practical Pathology. A Manual 
beautiful octavo volume of 497 pages, with 
$6.00. Just ready. 

It cannot often be said in these days of literary 
activity, that a book meets a distinct want, that it 
opens up new ground, and that it is sure to be 
largely in request. All these things are perfectly 
trueof the admirable and handsome volume before 
us. It is literally the first thorough attempt to deal 
fully with the subject of practical pathology, es- 
pecially in its histological aspect, and in manner 
and scope it stands alone. The vast majority of the 
figures interpolated in the text are colored, and 
colored so as to reproduce with tolerable exactitude 
the appearances of sections stained with various 



for Students and Practitioners. In one very 
136 exquisitely colored illustrations. Cloth, 

reagents. We have formed a very high opinion of 
this work, and we candidly admit that there is in 
it little to which exception could possibly be taken. 
It is manifestly the product of one who has him- 
self travelled over the whole field and who is skilled 
not merely in the art of histology, but in the obser- 
vation and interpretation of morbid changes. The 
work is sure to commapd a wide ciiculation. It 
should do much to encourage the pursuit of path- 
ology, since such advantages in histological study- 
have never before been ottered. — The Lancet, Jan. 
5, 1884. 



COBNIL, v., and MAJSTIFB, X., 

Prof, in the Faculty of Med. of Paris. Prof, in the College of France. 

A Manual of Pathological Histology. Translated, with notes and additions, 
by E. O. Shakespeare, M. D., Pathologist and Ophthalmic Surgeon to Philadelphia 
Hospital, and by J. Henry C. Simes, M. D., Demonstrator of Pathological Histology in 
the University of Pennsylvania. In one very handsome octavo volume of 800 pages, with 
860 illustrations. Cloth, $5.50 ; leather, $6.50 ; half Eussia, raised bands, $7. 



We have no hesitation in cordially recommend- 
ing the translation of Cornil and Ranvier's "Patho- 
logical Histology" as the best work of the kind in 
any language, and us giving to its readers a trust- 
worthy guide in obtaining a broad and solid basis 
for the appreciation of the practical bearings of 
pathological anatomy. — American Journal of the 
Medical Sciences, April, 1880. 

One of the most complete volumes on patholog- 
ical histology we have ever seen. The plan of study 



embraced within its pages is essentially practieaL 
Normal tissues are discussed, and after their thor- 
ough demonstration we are able to compare any- 
pathological change which has occurred in them. 
Thus side by side physiological and pathological 
anatomy go hand m hand, affording that best of 
all processes in demonstrations, comparison. The 
admirable arrangementof the work affords facility 
in the study of any part of the human economy. — 
New Orleans 3Iedical and Surgical Journal, June,1882. 



KLFIJSr, E., 31. JD., F. M. S., 

Joint Lecturer on General Anat. and Phys., in the Med. School of St. Bartholomew'' s Hosp. London. 
Elements of Histology. In one handsome pocket size 12mo. volume of 360 pages, 
with 181 illustrations. Limp cloth, red edges, $1.50. Just ready. (See Students' Series of 
Manuals, page 5.) 

Although an elementary work, it is by no means 
superficial or incomplete, for the author presents 
in concise language nearly all the fundamental facts 
regarding the microscopic structure of tissues. 



The illustrations are numerous and excellent. We 
commend Dr. Klein's Elements most heartily to 
the student. — Medical Record, Dec. 1, 1883. 



FEFFEB, A. J., 31. B., 31. S., F. B. C. S., 

Surgeon and Lecturer at St. Mary''s Hospital, London. 
Surgical Pathology. In one pocket-size 12mo. volume of 511 pages, with 81 
illustrations. Limp cloth, red edges, $2.00. Just ready. See Students' Scries of JLanuals, page 5. 
It is prepared especially to meet the requirements illustrations are numerous and well selected. The 
of the student, but contains much of interest for the arrangement is easy and natural. We would espo- 
general practitioner. The author has succeeded cially recommend it not only to students, but to all 
admirably in puttingthe work forward in the most who wish a concise and clear exposition of some of 

f)ractical form , and he deserves great praise for the the intricate problems of surgical pathology. — Xa^h- 
ucidity of style and brevity of descriptions. The ville Join-nal of 3fcdicine and Surgery, Jan."l8S-t. 



GBEEW, T. HEJSTBY, 31. JD., 

Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, ete^ 

Pathology and Morbid Anatomy, Fifth American from the sixtli enlargeti 
and revised English edition. In one very handsome octavo volume of about 350 pages, 
with about 150 ihie engravings. In press. 



SCHAFER'S PRACTICAL HISTOLOGY. In one 
handsome royal 12mo. volume of ;50S pages, with 
40 illustrations. 

GLUGE'S ATLAS OF PATHOLOGICAL HISTOL- 



OGY. Translated by .TosKru Lvirv, M. D. In 
one volume, very large imperial quarto, with 



320 coppor-plato figures, 
descriptive letter-press. 



plain and colored, and 
Cloth, S4.iX\ 



14 Henry C. Lea's Son & Co.'s Publications — Practice of Med. 



Prof, of the Principles and Practice of Med. and of Clin. Med. 



Bellevue Hospital Medical College, N. Y. 



A Treatise on the Principles and Practice of Medicine. Designed for 
the use of Students and Practitioners of Medicine. With an Appendix on the Kesearches 
of Koch, and their bearing on the Etiology, Pathology, Diagnosis and Treatment of 
Phthisis. Fifth edition, revised and largely rewritten In one large and closely-printed 
octavo volume of 1160 pages. Cloth, |5.50; leather, $6.50 ; very handsome half Eussia, 
raised bands, $7. Just ready. 

Koch's discovery of the bacillus of tubercle gives promise of being the greatest 
boon ever conferred by science on humanity, surpassing even vaccination in its benefits to 
mankind. In the appendix to his work. Professor Flint deals with the subject from a 
practical standpoint, discussing its bearings on the etiology, pathology, diagnosis, prog- 
nosis and treatment of pulmonary phthisis. Thus enlarged and completed, this standard 
work will be more than ever a necessity to the physician who duly appreciates the re- 
sponsibility of his calling. 



We cannot conclude this notice without express- 
ing our admiration for this volume, which is cer- 
tainly one of the standard text-books on medicine ; 
and we may safely affirm that, taken altogether, it 
exhibits a fuller and wider acquaintance with re- 
cent pathological inquiry than any similar work 
with which we are acquainted, and it shows its au- 
thor to be possessed of the rare faculties of clear 
exposition, thoughtful discrimination and sound 
judgment. — Lomlon Lancet, July 23, 1881. 

In a word, we do not know of any similar work 
which is at once so elaborate and so concise, so full 
and yet so accurate, or which in every part leaves 
upon the mind the impression of its being the pro- 
duct of an author richly stored with the fruits of 
clinical observation, and an adept in the art of con- 
veying them clearly and attractively to others. — 
American Journal of Medical Sciences, April, 1881. 

A well-known writer and lecturer on medicine 
recently expressed an opinion, in the highest de- 
gree complimentary of the admirable treatise of 
Dr. Flint, and in eulogizing it, he described it ac- 
curately as "readable and reliable." No text-book 
is more calculated to enchain the interest of the 
student, and none better classifies the multitudi- 
nous subjects included in it. It has already so far 



won its way in England, that no inconsiderable 
number of men use it alone in the study of pure 
medicine ; and we can say of it that it is in every 
way adapted to serve, not only as a complete guide, 
but also as an ample instructor in the science and 
practice of medicine. The style of Dr. Flint is 
always polished and engaging. The work abounds 
in perspicuous explanation, and is a most valuable 
textbook of medicine. — London Medical News. 

This work is so widely known and accepted as 
the best American text-book of the practice of 
medicine that it would seem hardly worth while to 
give this,' the fifth edition, anything more than a 
passing notice. But even the most cursory exami- 
nation shows that it is, practically, much more 
than a revised edition; it is, in fact, rather a new 
work throughout. This treatise will undoubtedly 
continue to hold the first place in the estimation 
of American physicians and students. No one of 
our medical writers approaches Professor Flint in 
clearness of diction, breadth of view, and, what we 
regard of transcendent importance, rational esti- 
mate of the value of remedial agents. It is thor- 
oughly practical, therefore pre-eminently the book 
for American readers. — St. Louis Clin. Bee, Mar. '81. 



Lately Professor of Hygiene in the University of Pennsylvania. 

Essentials of the Principles and Practice of Medicine. A Handbook 
for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one 
handsome royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, |2.75 ; half 
bound, $3.00. 

The author of this book seems to have spared no 
pains to bring it up to the modern standpoint, for 
as we turn over its pages we find many subjects 
introduced which have only lately been brought 
before the profession. Certainly amongst books of 
its class it deserves and has obtained a good posi- 
tion. On the whole it is a careful and conscien- 
tious piece of work, and may be commended. — 
London Lancet, June 24, 1882. 

Within the compass of 600 pages it treats of the 
history of medicine, general pathology, general 
symptomatology, and physical diagnosis (including 



laryngoscope, ophthalmoscope, etc.), general ther- 
apeutics, nosology, and special pathology and prac- 
tice. With such a wide range, condensation is, of 
course, a necessity ; but the author has endeavored 
to make up for this by copious references to original 



papers, etc. We cannot but admit that there is a 
wonderful amount of information contained in this 
work, and that it is one of the best of its kind that 
we have seen. — Glasgoio Medical Journal, Nov. 1882. 
An indispensable book. No worli ever exhibited 
a better average of actual practical treatment than 
this one ; and probably not one writer in our day 
had a better opportunity than Dr. Hartshorne for 
condensing all the views of eminent practitioners 
into a 12mo. The numerous illustrations will be 
very useful to students especially. These essen- 
tials, as the name suggests, are not intended to 
supersede the text-books of Flint and Bartholow, 
but they are the most valuable in affording the 
means tb see at a glance the whole literature of any 
disease, and the most valuable treatment. — Chicago 
3Iedical Journal and Examiner, April, 1882. 



BMISTOWB, JOMJSr STJEB, M. D., F. M. C. JP., 

Physician and Joint Lecturer on Medicine at St. Thomas^ Hospital. 

A Treatise on the Practice of Medicine. Second American edition, revised 
by the Author. Edited, with additions, by James H. Hutchinson, M.D., physician to the 
Pennsylvania Hospital. In one handsome octavo volume of 1085 pages, with illustrations. 
Cloth, $5.00 ; leather, $6.00 ; very handsome half Eussia, raised bands, $6.50. 



The second edition of this excellent work, like 
the first, has received the benefit of Dr. Hutchin- 
son's annotations, by which the phases of disease 
which are peculiar to this country are indicated, 
and thus a treatise which was intended for British 
practitioners and students is made more practically 
useful on this side of the water. We see no reason 
to modify the high opinion previously expressed 
with regard to Dr. Bristowe's work, except by add- 
ing our appreciation of the careful labors of the 



author in following the latest growth of medical 
science. — Boston Medical and Surgical Journal, Feb. 
1880. 

The reader will find every conceivable subject 
connected with the practice of medicine ably pre- 
sented, in a style at once clear, interesting and 
concise. The additions made by Dr. Hutchinson 
are appropriate and practical, and greatly add to 
its usefulness to American readers. — Buffalo Med- 
ical and Surgical Journal, March, 1880. 



Henry C. Lea's Son & Co.'s Publications — Practice of Med. 15 
MBYWOLDS, J. MUSS JELL, M. D., 

Profesaor of the Principles and Practice of Medicine in University College, London. 

A System of Medicine. With notes and additions by Henry Hartshoene, 
A. M., M. D., late Professor of Hygiene in tlie University of Pennsylvania. In three large 
and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- 
tions. Price per volume, cloth, $5.00 ; sheep, $6.00 ; very handsome half Russia, raised bands, 
$6.50. Per set, cloth, $15 ; sheep, $18 ; half Russia, $19.50. Sold only by subscription. 
VoEuiiE I. Contains General Diseases and Diseases of the Nervous System. 
YoLUiviE II. Contains Diseases of Respiratory and Circulatory Systems. 
Volume III. Contains Diseases of the Digestive, Blood-Glandular, Urinary, Re- 
productive and CuTAJSfEous Systems. 

Reynolds' System of Medicine, recently completed, has acquired, since the first ap- 
pearance of the first volume, the well-deserved reputation of being the work in which 
modem British medicine is presented in its fullest and most practical form. This could 
scarce be otherwise in view of the fact that it is the result of the collaboration of the lead- 
ing minds of the profession, each subject being treated by some gentleman who is regarded 
as its highest authority. All the leading schools in Great Britain have contributed their 
best men, in generous rivalry, to build up this monument of medical science. That a work 
conceived in such a spirit and carried out under such auspices should prove an indis- 
pensable treasury of facts and experience, suited to the daily wants of the practitioner, was 
inevitable ; and the success which it has enjoyed in England, and the reputation which 
it has acquired on this side of the Atlantic, have sealed it with the approbation of the 
two pre-eminently practical nations. 

Its large size and high price having kept it beyond the reach of many practitioners in 
this country who desire to possess it, a demand has arisen for an edition at a price which 
shall render it accessible to all. To meet this demand the present edition has been under- 
taken. The five volumes and five thousand pages of the original have, by the use of a 
smaller type and double columns, been compressed into three volumes of over three 
thousand pages, clearly and handsomely printed, and offered at a price which renders it 
one of the cheapest works ever presented to the American profession. 

But not only is the American edition more convenient and lower priced than the Eng- 
lish ; it is also better and more complete. Some years having elapsed since the appearance 
of a portion of the work, additions were required to bring up the subjects to the existing con- 
dition of science. Some diseases, also, which are comparatively unimportant in England, 
require more elaborate treatment to adapt the articles devoted to them to the wants of the 
American physician ; and there are points on which the received practice in this country 
differs from that adopted abroad. The supplying of these deficiencies has been undertaken 
by Henry Hartshorne, M. D., late Professor of Hygiene in the University of Pennsyl- 
vania, who has endeavored to render the work fully up to the day, and as useful to the 
American physician as it has proved to be to his English brethren. The number of illus- 
trations has also been largely increased, and no effort spared to render the typographical 
execution unexceptionable in every respect. 



There is no medical work which we have in 
times past more frequently and fully consulted 
when perplexed by doubts as to treatment, or by 
having unusual or apparently inexplicable symp- 
toms presented to us, than " Reynolds' System of 
Medicine." It contains just that kind of informa- 
tion which the busy practitioner frequently finds 
himself in need of. In order that any deficiencies 
may be supplied, the publishers have committed 
the preparation of the book for the press to Dr. 
Henry Hartshorne, whose judicious notes distrib- 
uted throughout the volume afford abundant evi- 
dence of the thoroughness of the revision to which 
he has subjected it. — American Journal of the Med- 
ical Sciences, Jan. 1880. 

Certainly no work with which we are acquainted 
has ever been given to the English-reading profes- 
sion which treats of so many diseases in a manner 



so concise and thorough, and withal so lucid and 
trustworthy. In that branch of medicine in which 
the rank and file of the profession are mainl}' in- 
terested, viz., the practical part, therapeutics, Rey- 
nolds, without intending any invidious comparison, 
stands pre-eminent. The therapeutics of the Eng- 
lish correspond more closely than those of any 
other country with those of this country, and the 
American editor of Reynolds' has brought this 
branch up to the most advanced American stand- 
ard. — Michigan Medical Neics, Feb. 15, ISSO. 

These three volumes are a whole library in and 
of themselves. As works of reference tliey are 
destined to be for many years regarded as the 
very highest authority on medical subjects. Lan- 
guage is scarcely adequate to express the actual 
value to general practitioners of such a system of 
medicine as this. — Cincinnati Lancet and Clinic. 



WATSON, THOMAS, M. L>., 

Late Phi/sician in Ordbiarji to the Queen. 

Lectures on the Principles and Practice of Physic. Delivered at King's 
College, I^ondon. A new American from the fifth English edition, revised and enlarged. 
Edited, with additions, and 190 illustrations, by Henry Hartshorne, A. ;M., ^L D., late 
Professor of Hygiene in the University of Pennsylvania. In two large and handsome octavo 
volumes, containing 1840 pages. Cloth, $9.00 ;' leather, $11.00. 

WOODBUMY, FBAWK, M. I)., 

Phi/sician to the German Hospital, Philadelphia ; late Chief Assistant to the Mfiiical Clinic in Jeffr- 

son College IIos})iial, etc. 

A Handbook of the Principles and Practice of Medicine. For the use 

of Students and l*ractitioviers. In one royal 12mo. volume, with illustrations. Preparing. 

A CENTURY OF AMKKICAN MKDICINK, 1776-1876. By Drs. E. H. Cuvkkk, H. J. 

BiGKLOw, S. D. Guoss, T. (.i. Thomas, and ,1. S. Bu,mn«s. In one l'2mo. volume of 370 pages. Cloth.- S"2.25. 



16 Henry C. Lea's Son & Co.'s Publications — Clinical Med., etc. 



FOTSEHGILL, J. M., 3I. I>., JEdhi., M. B. C. JP., Zond., 

Asst. Phys. to the West Lond. Hosp., Asst. Phys. to the City of Lond. Hosp., etc. 

The Practitioner's Handbook of Treatment ; Or, The Principles of Thera- 
peutics. Second edition, revised and enlarged. In one very handsome octavo volume of 651 
Cloth, $4.00 ; very handsome half Kussia, raised bands, |5.50. 

impress of a master-hand; and while the work is 
thoroughly scientific in every particular, it presents 
to the thoughtful reader all the charms and beau- 
ties of a well-written novel. No physician can 
well afford to be without this valuble work, for its 
originality makes it fill a niche in medical litera- 
ture hitherto vacant. — Nashville Journ. of Med. and 
Surg., Oct. 1880. 

The junior members of the profession will find 
it a work tiiat should not only be read but care- 
fully studied. It will assist them in the proper 
selection and combination of therapeutical agents 
best adapted to each case and condition, and 
enable them to prescribe intelligently and success- 
fully .—*Se. Louis Courier of Medicine, Nov. 1880, 



A book which can give correctly and interest- 
ingly, as well as scientifically, the method of 
prescribing and the rationale of the best thera- 
peutics in the treatment of disease, is manifestly 
just the work which each physician desires. It is 
not extravagant eulogy to say that the physician 
will find in this work of Fothergill the guide which 
he seeks for his therapeutics; for not only is the 
treatment which he seeks already indicated" herein, 
but the rationale of the treatment is as clearly ex- 
plained. — Gaillard's Med. Journ., Sept. 1880. 

The author merits the thanks of every well-edu- 
cated physician for his eflTorts toward rationalizing 
the treatment of diseases upon the scientific basis 
of physiology. Every chapter, every line, has the 



FLIWT, AJISTIW, M. D. 

Clinical Medicine. A Systematic Treatise on the Diagnosis and Treatment of 
Diseases. Designed for Students and Practitioners of Medicine. In one large and hand- 
some octavo volume of 799 pages. Cloth, $4.50 ; leather, $5.50 ; half Russia, $6.00. 

It is here that the skill and learning of the great 
clinician are displayed. He has given us a store- 
house of medical knowledge, excellent for the stu- 
dent, convenient for the practitioner, the result of 



long life of the most faithful clinical work, col- 
lected by an energy as vigilant and systematic as 
untiring, and weighed by a judgment no less clear 
than his observation is close. — Archives of Medicine, 
Dec. 1879. 

To give an adequate and useful conspectus of the 
extensive field of modern clinical medicine is a task 
of no ordinary difficulty; but toaccomplish this con- 
sistently with brevity and clearness, the different 
subjects and their several parts receiving the 
attention which, relatively to their importance, 
medical opinion claims for them, is still more diffi- 
cult. This task, we feel bound to say, has been 
executed with more than partial success by Dr. 
Flint, whose name is already familiar to students 



of advanced medicine in this country as that ol 
the author of two woi'ks of great merit on special 
subjects, and of numerous papers exhibiting much 
originality and extensive research. — The Dublin 
Journal, Dec. 1879. 

The great object is to place before the reader 
the latest observations and experience in diagnosis 
and treatment. Such a work is especially valuable 
to students. It is complete in its special design, 
and yet so condensed that they can by its aid keep 
up with the lectures on practice without neglec<>- 
ing other branches. It will not escape the notice 
of the practitioner that such a work is most valu- 
able in culling points in diagnosis and treatment 
in the intervals between the daily rounds of visits, 
since he can in a few minutes refresh his memory 
or learn the latest advance in the treatment of 
diseases which demand his instant attention. — 
Cincinnati Lancet and Clinic, Oct. 25, 1879. 



By the Same Author. 
Essays on Conservative Medicine and Kindred Topics. In one very hand- 
some royal 12mo. volume of 210 pages. Cloth, $1.38. 

FINLAYSOJS-, JAMFS, M. J}., Editor, 

Physician and T^ecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. 
Clinical Diagnosis. A Handbook for Students and Practitioners of Medicine, 
With Chapters by Prof. Gairdner on the Physiognomy of Disease ; Prof. Stephens on 
Diseases of the Female Organs; Dr. Eobertson on Insanity; Dr. Gemmeli on Physical 
Diagnosis ; Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor 
on Case-taking, Family History and Symptoms of Disorder in the Various Systems. In 
one handsome 12mo. volume of 546 pages, with 85 illustrations. Cloth, $2.63. 

bulkier vouames; and because of its arrangement 
and complete index it is unusually convenient for 
quick reference in any emergency that may com© 
upon the busy practitioner. — N. C. Med. Journ., 
Jan. 1879. 



This is one of the really useful books. It is at- 
tractive from preface to "the final page, and ought 
to be given a place on every office table, because it 
contains in a condensed form all that is valuable 
in semeiology and diagnostics to be found in 



FBNWICK, SAMUFL, M. D., 

Assistant Physician to the London Hospital. 

The Student's Guide to Medical Diagnosis. From the third revised and 
enlarged English edition. In one very handsome royal 12mo. volume of 328 pages, with 
87 illustrations on wood. Cloth, $2.25. 



TANWEB, TMOIIAS JSAWKFS, M. D. 

A Manual of Clinical Medicine and Physical Diagnosis. Third American 
from the second London edition. Eevised and enlarged by TiiiBURY Fox, M. D., Phy- 
sician to the Skin Department in University College Hospital, London, etc. In one small 
12mo. volume of 362 pages, with illustrations. Cloth, $1.50. 



STURGES' INTRODUCTION TO THE STUDY 
OF CLINICAL MEDICINE. Being a Guide to 
the Investigation of Disease. In one handsome 
12mo. volume of 127 pages. Cloth, $1.25. 

DAVIS' CLINICAL LECTURES ON VARIOUS 



IMPORTANT DISEASES ; being a collectioa ot 
the Clinical Lectures delivered in the Medical 
Ward of Mercy Hospital, Chicago. Edited hj 
Frank H. Davis, M. D. Second edition. In one 
royal 12mo. volume of 287 pages. Cloth, §1.75. 



Henry C. Lea's Son & Co.'s Publications — Electric, Prac, etc. 17 



niCHAnnsojsr, b. w., m.a., m.jd., ll. d., f.b.s., f.s.a. 

Felloio of the Royal College of Physicians, London. 
Preventive Medicine. In one octavo volume of 729 pages. Cloth, $4; leather, 
$5 ; very handsome half Russia, raised bands, |5.50. Just ready. 



presented can be found so systematically arranged 
and intelligently presented. — The Sanitarian^ 
March, 1884. 

This is a book that will surely find a place on the 
table of every progressive physician. To the 
medical profetsionj whose duty is quite as much to 
prevent as to cure disease, the book will be a boon. 
— Boston Medical and Surgical Journcd, Mar. G, 1884. 

The treatise contains a vast amount of solid, valu- 
able hygienic information. — Medical and Surgical 
Reporter, Feb. 23, 1884. 



Though this work has been written with spe- 
cial reference to non-professional readers, it excels 
any other book which has before fallen under our 
observation on the subject of which it treats, as a 
text-book for the medical reader. It comprehends 
the nature, causes and prevention of disease from 
a strictly scientific standpoint. The American 
publishers have done the medical profession a 
valuable service in laying it before them as a 
work that contains much with which every phy- 
sician should be familiar. There is no other work 
in the language in which the information here 

Excerpt from Contents. 

I. — Disease as a Unity, with a variety of Phenomena. The Preventive Scheme of 
Medicine. General Diseases of Mankind. 1. Constitutional Diseases. 2. Local Diseases. 
3. Diseases from Natural Accidents, — Lightning — Sunstroke — Starvation — Poisons — 
Venoms — Poisonous Food — Pregnancy. II. Acquired Diseases of Artificial Origin ; 
Phenomena and Course. 1. Acquired Diseases from Inorganic and Organic Poisons, — 
Tea — Coffee — Alcohol — Tobacco — Soot — Gases. 2. Acquired Diseases from Physical 
Agencies, Mechanical and General, — Dusts — Pressure on Lungs — Concussions and Shocks 
— Muscular Overwork and Strain — Acquired Deformities — Physical Injuries — Surgical 
Operations. 3. Acquired Diseases from Mental Agencies, — Moral, Emotional and 
Habitual. Diseases from Mental Shock, from Moral Contagion, — Tarantism — Suicide, 
from Hysterical Emotion, from Passion, from Habits of Life — Insomnia — Dementia — 
Sloth — Luxury — Secret Immorality. III. — 1. Origins and Causes of Disease, — Congenital, 
Hereditary or Constitutional Causes ; Atmospheric and Climatic Causes ; Parasitic Causes, 
— Bacteria — Bacilli — Spirilla — Trichinse ; Zymotic Causes; Industrial and Accidental 
Causes; Social and Psychical Causes; Senile Degenerative Causes. 2. Preventions of 
Disease. Prevention of Hereditary or Constitutional Diseases, — Personal Pules for Preg- 
nancy, Infancy, Adolescence, Maturity ; Prevention of Atmospheric and Climatic Diseases ; 
of Parasitic Diseases, — Personal Pules ; of Zymotic Diseases, — Contagion — Drainage — 
Isolation of Sick — Water and Milk vSupply — Hospitals — Pegistration — Vaccination — 
Other Inoculations — Legislation ; Prevention of Industrial Diseases — Lead Poisoning — 
Dusts — Gases, etc. ; Prevention of Social and Psychical Diseases, — Warming and Ventila- 
tion — Light — Water — the Bed-room — Bread — Abattoirs — Schools — Sepulture — Drunken- 
ness ; Prevention of Senile Disease. 



BABTMOLOW, BOBBBTS, A. M., 31. JD., LB. B., 

Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc. 

A Practical Treatise on the Applications of Electricity to Medicine 



and Surgery, 
109 illustrations 



Second edition. 
Cloth, $2.50. 



In one very handsome octavo volume of 292 pages, with 



The second edition of this work following so 
soon upon the first would in itself appear to be a 
sufficient announcement; nevertheless, the text 
has been so considerably revised and condensed, 
and so much enlarged by the addition of new mat- 
ter, that we cannot fail to recognize a vast improve- 
ment upon tiie former work. The author has pre- 
fiared his work for students and practitioners— for 
hose who have never acquainted themselves with 
the subject, or, having done so, find that after a 
time their knowledge needs refreshing. We think 
he has accomplished this object. The book is not 
too voluminous, but is thoroughly practical, sim- 
ple, complete and comprehensible. It is, more- 
over, replete with numerous illustrations of instru- 
ments, appliances, etc. — Medical Record, November 
15, 1882. 



A most excellent work, addressed by a practi- 
tioner to his fellow-practitioners, and therefore 
thoroughly practical. The work now before us 
has tlie exceptional merit of clearly pointing out 
where the benefits to be derived from electricity 
must come. It contains all and everything that 
the practitioner needs in order to understand in- 
telligently the nature and laws of tiie agent he la 
making use of, and for its proper application in 
practice. In a condensed, practical form, it pre- 
sents to tlie physician all that he would wish to 
rememberafter perusing a whole lil)rary on medical 
electricity, including the results of the latest in- 
vestigations. It is the book for the practitioner, 
and tTie necessity for a second edition prove^ thai 
it has been appreciated by the profession. — Physi- 
cian and Surgeon, Dec. 1SS2. 



BLABBBSIIOW, S. O., M. B., 

Senior Physician to a)ui late Lect. on Principles and Practice of Med. at Guy's Hospitaf, London. 
On the Diseases of the Abdomen; Comprising those of the Stomach, and 
other parts of tlic Alimentary Canal, G^lsophagus, Caecum, Intestines and Peritoneum. Second 
American from third enlarged and revised English edition. In one hamisome ootiiro 
volume of 554 pages, with illustrations. Cloth, |3.50. 



PAVY'S TREATISE ON TIIE FUNCTION OF DI- 
GESTION; its Disorders and their Treatment. 
From the second London edition. In one octavo 
volume of 2:58 pages. Cloth, ^2.00. 

CHAMBERS' MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one hand- 
some octavo volume of 302 pp. Cloth, $2.75. 



BARLOW'S MANUAL OF THE TUAOTIOE OF 
MEDICINE. With additions by 1>. F. Condih, 
]M. D. 1 vol. Svo., pp. (>0;>. Cloth, S-J.">0. 

TODIVS CLINICAL LEt^rURES ON CERTAIN 
ACUTE DISEASES. In cue octavo volume of 
3-20 pages. Cloth, $2.50. 

HOLLAND'S JIEDICAL NOTES AND REFLEX)- 
TIONS. 1 vol. Svc, pp. 493. Cloth, §3.50. 



18 Henry C. Lea's Son & Co.'s Publications — Throat, L<img-s, etc. 
SBILEB, CAUL, 31. JD., 

Lecturer on Laryngoscopy in the University of Pennsylvania. 

A Handbook of Diagnosis and Treatment of Diseases of the Throat, 
Nose and Naso-Pharynx. Second edition. In one handsome royal 12mo. volume 

of 294 pages, with 77 illustrations. Cloth, $1.75. Just ready. 

Dr. Sellers book is a clear, concise, practical I Dr. Seiler's treatise contains all the essentials of 
exposition of the subject, such as only a master of the knowledge of the important localities com- 
it could have written. It is better suited to the pressed into a small space and put together by 
wants of advanced students and young physicians i one of the ablest of American specialists. To stu- 
than any other at present in the hands of the pro- dents and others this book can be recommended 
fession. — American Practitioner, Aug, 18S3. as one of the best and most generally useful. — 

\ Canada Medical and Surgical Journal, July, 1883. 



BBOWJSIE, LJEJSnSOX, F. B. C. S., JEdin., 

Senior Surgeon to the Central London Throat and Ear Hospital, etc. 
The Throat and its Diseases. Second American from the second English edi- 
tion, thoroughly revised. With 100 typical illustrations in colors and 50 wood engravings, 
designed and executed by the Author. In one very handsome imperial octavo volume of 
about 350 pages. Preparing. 

FLINT, AUSTIJS^, M. D., 

Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, If. T. 

A Manual of Auscultation and Percussion ; Of the Physical Diagnosis of 
Diseases of the Lungs and Heart, and of Thoracic Aneurism. Thuxl edition. In one hand- 
some royal 12mo. volume of 240 pages. Cloth, $1.63. Just ready. 

This practical and justly popular manual is con- termined by analysis, and as based particularly on 
veniently divided into eight chapters, and the the variations in the intensity, pitch and quality 
student is gradually led up from a general con- ] of sounds; to impress the facts upon the student 
sideration of physical signs in health and disease . and reader that the significance of physical signs 
to the differential diagnosis of diseased conditions relates to certain physical conditions, and that 
by a knowledge of these physical signs. As in his close study of the physical conditions in health 
courses of practical instruction, so in this book and disease is a sine qua non of success in both 
the authors plan is to simplify the subject as diagnosis and treatment. — The Medical News, 
much as possible : to consider the distinguishing ; April 28, 1883. 
eharacteristics of different physical signs as de- i 



By the Same Author. 
Physical Exploration of the Lungs by Means of Auscultation and 
Percussion. Three lectures delivered before the Philadelphia County Medical Society, 
1882-83. In one handsome small 12mo. volume of 83 pages. Cloth, SI. 00. 

By the Same Author. 
A Practical Treatise on the Physical Exploration of the Chest and 
the Diagnosis of Diseases Affecting the Bespiratory Organs. Second and 

revised edition. In one handsome octavo volume of 591 pages. Cloth, §4.50. 

By the Same Author. 
Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and 
Complications, Fatality and Prognosis, Treatment and Physical Diag- 
nosis ; In a series of Clinical Studies. In one handsome octavo volume of 442 pages. 

Cloth, §3.50. 

By the Same Author. 
A Practical Treatise on the Diagnosis, Pathology and Treatment of 
Diseases of the Heart. Second revised and enlarged edition. In one octavo volume 
©f 550 pages, with a plate. Cloth, $4. 

GBOSS, S. 2>., ilX.jD., LL,L>., D.C.L. Oxon.. LL.B. Cantab, 

A Practical Treatise on Foreign Bodies in the Air-passages. In one 
octavo volume of 452 pages, with 59 illustrations. Cloth, !:?2.75. 

FULLER ON DISEASES OF THE LL3GS AND STOKES' LECTURES ON FEVER. Edited by 

AIR-PASSAGES. Their Pathology, Physical Di- John William Moore, M. D., F. K. Q. C. P. In 

agnosis, Symptoms and Treatment. From the one octavo volume of 280 pages. Cloth, $2.00. 

second and revised English edition. In one 

octavo volume of 475 pages. Cloth, S3.o0. A TREATISE ON FEVER. Bv Robeet D. Lyons, 

SLADE ON DIPHTHERIA; its Nature and Treat- K. C. C. In one 8vo. vol. of 35i pp. Cloth, $2.25. 

ment, with an accoiint of the History of its Pre- ^jlli^mS ON PULMONARY CONSUMPTION ; 

valence m various Countries. Second andrevised -^^ ^^^nre. Varieties and Treatment. With an 

edition. In one 12mo. vol., pp. lo8. Cloth, Sl.2o. ^nalvsis of one thousand cases to exemplify its 

LECTURES ON THE STUDY OF FEVER. By duration. In one Svo. vol. of 303 pp. Cloth, $2.50. 

A. HuDSOx, M. D., M. R. I. A. In one octavo 

volum.e of 308 pages. Cloth, S2.50. LA ROCHE ON YELLOW FEVER, considered in 

SMITH ON CONSUMPTION: its Earlv andReme- its Historical Pathological Etiological and 

diable Stages. 1 vol. 8vo., pp. 253. S2.25. Therapeutical Relations In two large and hand- 

LA ROCHE ON PNEUMONIA. 1 vol. Svo. of 490 ^«™^ °^^^^° ^°^^^^^' °^ ^^^ PP" ^^°^^' ^•^• 

pages. Cloth, S3.00. CLINICAL OBSERVATIONS ON FUNCTIONAL 

WALSHE ON THE DISEASES OF THE HEART NERVOUS DISORDERS, by C. Handfiixd Jones, 

AND GREAT VESSELS. Third American edi- M. D. Second American edition. In one hand- 

tion. In 1 vol. 8vo., 416 pp. Cloth, §3.00. ' some octavo volume of 340 pages. Cloth, $3.25. 



Henry C. Lea's Son & Co.'s Publications — Nerv. audMent. Dis.,etc. 19 
HAMILTOW, ALLAJSr McLANE, M. D., 

Attending Physician at the Hospital for Epileptics and Paralytics, BlackweWs Island, N. Y., and at 
the Out-Patients' Department of the New York Hospital. 

Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly- 
revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, 



We are glad to welcome a second edition of so use- 
ful a work as this, in which Dr. Hamilton has suc- 
ceeded in condensing into convenient limits the 
most important of the recent developments in re- 
gard to diseases of the nervous system. Of recent 
years nervous pathology has attained to such im- 
portance as to necessitate very careful description 
m special works, and among these this volume 
must take a high place. This volume is on the whole 
excellent, and is devoid of that spirit of plagiarism 
which we have unfortunately seen too much of in 
certain recent English works on nervous diseases. 
— Edinburgh Medical Journal, May, 1882. 



When the first edition of this good book appeared 
we gave it our emphatic endorsement, and the 

E resent edition enhances our appreciation of the 
ook and its author as a safe guide to students of 
clinical neurology.' One of the Vjest and most 
critical of English neurological journals. Brain, ha.s 
characterized this book as the best of its kind in 
any language, which is a handsome endorsement 
from an exalted source. The improvements in the 
new edition, and the additions to it, will justify its 
purchase even by those who possess the old. — 
Alienist and Neurologist, April, 1882. 



TUKJE, DAiaEL MACK, M. D., 

Joint Author of The Manual of Psychological Medicine, etc. 

Illustrations of the Influence of the Mind upon the Body in Health 
and Disease. Designed to elucidate the Action of the Imagination. New edition. 
Thoroughly revised and rewritten. In one handsome octavo volume of 467 pages, with 
two colored plates. Cloth, $3.00. Just ready. 

The immense power of the imagination, both in causing and curing disease, has been 
recognized from the infancy of medical science, but the practical application of this fact 
has hitherto been chiefly confined to charlatans and has always been one of the secrets of 
their frequent success. To rescue this invaluable therapeutic agent from unmerited ill- 
repute, and to obtain its recognition as a legitimate instrument of the regular profession, 
is briefly the object of this volume. Not only is the work thus one of high importance 
to the practitioner who desires to utilize all the resources of his art, but in its authentic 
revelations of the fantastic interaction of man's dual nature, it rivals in some of its narratives 
the most interesting creations of fiction. The favor with which the work has hitherto 
been received will be enhanced by the labor bestowed in the revision as well as by the 
addition of two carefully prepared colored plates. 



CLOJISTOJSr, THOMAS S., M. J}., F. M. C. JP., L. M. C. S., 

Lecturer on Mental Diseases in the University of Edinburgh. 

Clinical Lectui ss on Mental Diseases. With an Appendix, containing an 
Exhaustive Summary of the Laws in Force in the United States upon the Commit- 
ment and Confinement of the Insane. By Charles F. Folsom, M. D., Assistant Pro- 
fessor of Mental Diseases, Medical Department of Harvard University. In one hand- 
some octavo volume of about 600 pages, illustrated with woodcuts and eight lithographic 
plates, four of which are beautifully colored. Cloth, |4. In a few days. 

At the author's request. Professor Folsom has critically examined this work, and has 
specially prepared for it the appendix on United States laws relating to the insane. The 
work will thus afford American practitioners a complete and trustworthy guide in medical 
and legal questions arising from cases of mental disease. 

viewed as a proof of the thoroughness of the work 



We should say that to have read a book like Dr. 
Clouston's lectures, and mastered his definitions, 
must make a man as well prepared as books can 
make him, to recognize the principal symptoms 
of insanity. We feel that every statement has 
been weighed, considered and viewed in many 
different relations. The student gets all the in- 
formation about the symptoms and treatment of 
insanity in well considered words. It may be 



and the originality of the author, that so mucii care 
has been taken with the therapeutics of insanity. 
Dr. Clouston has sought out and thought out, by 
observation and experiment, methoils of treatment 
suitable to the various forms of insanity, which 
constitute, perhaps, the most valuable features of 
the book. — Edinburgh Medical Journal, Feb. 18S4. 



JPLAYFAIM, W. S., M. D., F. B. C. F. 

The Systematic Treatment of Nerve Prostration and Hysteria. In 

one handsome small 12mo. volume of 97 pages. Cloth, SJ^l.OO. Just ready. 



The book is well worth perusal, and will repay 
anyone for the time spent in its careful study, in- 
asmuch as it will lead to a better understanding of 
the managomont of those betes noirs of the physi- 
cian, nerve prostration and hysteria. Details 'are 
given of the manner of carrying out the treatment, 



to which are added the histories of a number of 
cases illustrative of the method and it<< results. 
.\n appendix contains a description of the method 
of performing massage, which is clear and con- 
cise. — New Orleans Medical and Surtjical Joiirualf 
IMay, 1883. 



MFFCHFLL, S. WEIB, 31. D., 

Physician to Orthopa'dic Hospital and the Jnjirinary for Diseases of the Nervous System, Phila., 6te, 

Lectures on Diseases of the Nervous System; Especially in Women. 
Second edition. In one very h:ui(Lsonio \'2mo. volume oi' about 'JoO pages. Prcpariii-g. 

* Blandford on Insanity and its Treatment: Lectures on the Treatment, 
Medical! and Legal, of Insane Patients. ^Vith a Summary of the Laws in force in the 
United States on the Confmement of the Insane, by Is.v.vo R.vy, M. I>. In one very 
handsome octavo volume. 



20 



Henry C. Lea's Son & Co.'s Publications — Siirg-ery. 



GBOSS, S. D., 31. D., LL. D., JD. C. L. Oxon., XX. 1>. 
Canfab.f 

Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. 
A System of Surgery : Pathological, Diagnostic, Therapeutic and Operative. 
Sixth edition, thoroughly revised and greatly improved. In two large and beautifully- 
printed imperial octavo' volumes containing 2382 pages, illustrated by 1623 engravings. 
Strongly bound in leather, raised bands, $15 ; half Eussia, raised bands, $16. 
The work as a whole needs no commendation. ' fully maintains the reputation the work has ac- 



Many years aso it earned for itself the enviable rep- 
utation of t!ie' lending American work on surgery, 
and it is still capable of maintaining that standard. 
The reason for this need only be mentioned to Vje 
appreciated. The author has always been calm 
and judicious in his statements, has based his con- 
clusions on much study and personal experience, 
ha,s been able to srasp'his subject in its entirety, 
and, above all, has conscientiously adhered to 
truth and fact, weighing the evidence, pro and 
eon, accordingly. Aconsiderable amount of new 
material has Seen introduced, and altogether the 
distinguished author has reason to be satisfied 



quired. It has become a complete and systematic 
book of reference alike for the student and the 
practitioner. — The London Lancet, Jan. 27, 1S83. 

We regard Gross' System of Surgerj' not only as 
a singularly rich storehouse of scientific informa- 
tion, but as marking an epoch in the literary his- 
tory of surgery. The present edition h.as received 
the most careful revision at the hands of the emi- 
nerit author himself, assisted in various instances 
by able specialists in various branches. All depart- 
ments of the vast and ever-increasing literature of 
the science have been drawn upon for their most 
recent expressions. The late advances made in 



that he has placed the work fully abreast of the ; surgical practice have been carefully noted, such 
state of our knowledge. — Med. Record, yox. IS, 1S&2. as t^ie recent developments of List'erism and the 



We I'.ave purposely abstained, from comment or 
criticism of the book before us. It has formerly 
been noticed more than once in our columns, and it 
is enough now to remark that the present edition 



improvements in gynsecological operations. In 
every respect the work reflects lasting credit on 
American m.edical literature. — Medical and Surgical 
Reporter. Nov. 11, 1882. 



ASMBJIBST, JOMJS, Jr., M. X>., 

Professor of Clinical Surgery, Univ. of Penna., Surgeon to the Episcopal Hospital, Philadelphia^ 

The Principles and Practice of Sui'gery. Third edition, enlarged and re- 
vised. In one large and handsome octavo volimie of 1060 pages, with 555 illustrations. 
Cloth, $6 ; leather, §7 ; very handsome half Eussia, raised bands, $7.50. 

Dr. Ashhurst's Surgery is a condensed treatise the work must be its best claim for continued 
covering the vrhole domain of the science in one popularity with students and practitioners. In 
manageable volume. The present edition has had fact, in tliis respect it is without an equal in any 
a thorough revision. The novelties in surgical language. In the present edition many novelties 
practice and the recent observations in surgical in surgical practice are introduced, many modifi- 
science have been incorporated, but the size of the ; cations of previous statements made, and several 
volume lias not been materially increased. The ' new illustrations added. — Med. Pec, Nov. IS, 1882. 



author's arrangement is perspicuous, and his 
language correct and clear. An excellent index 
closes the work, and on the whole Ave consider it 
the best system of surgery in one volume which 
could be named as the product of an American 
author. — Medical and Surgical Reporter, Oct. 28, '82. 

The author, long known as a thorough student 
of surgery, and one of the most accomplished 
schol.'irs in the country', aims to give in this work 



It treats in a very thorough and satisfactory 
manner all the subjects in the various departments 
of surgery. The medical student and general prac- 
titioner of medicine will find it admirably adapted 
to their wants, the former as a text-book, and the 
latter as a most valuable work of reference when 
he wishes to refresh his mind and obtain the latest 
information on any subject of surgery. While 
there are no omissions or abridgements of any 
"a condensed but comprehensive description of description or discussions essential for imparting 



the modes of practice now generally employed in 
the treatment of surgical affections, with a plain 
exposition of the principles upon which these 
modes of practice are based." In this he has so 
well succeeded that it will be a surprise to the 
reader to know how much practical knowledge ex- 
t-ending over such a wide range of research is com- 
pressed in a volume of this size. This feature of 



a thorough knowledge of any principle or practice, 
yet unnecessary details and lengthy statements of 
views of various writers are excluded. In revising 
his work for a third edition, the author has spared 
no pains to render it worthy of a continuance of 
the favor with which it has heretofore been re- 
ceived. We predict an increasing demand for 
the work. Cincinjiati Medical Sews, Nov., 1882. 



GIBXBT, V. P., 31. X>. 

Surgeon to the Orthopaedic Hospital, New York, etc. 
Orthopsedie Sui'gery. For the use of Practitioners and Students. In one hand- 
some octavo volume, profusely illustrated. Preparing. 

B^OBJEJRTS, JOSJS^ B., A. 31., 31. J)., 

Lecturer on Anatomy and on Operative Surgery at the Philadelphia School of Anatomy. 

The Principles and Practice of Surgery. For the use of Students and 
Practitioners of Medicine and Surgery. In one very handsome octavo volume of about 500 
pages, with many illustrations. Preparing. 



BBLLA31Y, EDWABn, F. B. C. S. 

Operative Surgery. In active preparation. See Student^ Series of Mamiah, page 5, 



STI3ISOX, LBWIS A., B. A 

Prof, of Pathol. Anat. at the Univ. of the City 

A Manual of Operative Surgery. 

of 477 pages, with 332 illustrations. Cloth, $ 
This volume is devoted entirely to operative sur- 
gery', and is intended to familiarize the student 
with the details of operations and the different 
modes of performing them. The work is hand- 
somely illustrated, and the descriptions are clear 
and well-drawn. It is a clever and useful volume : 



., 31. n., 

of New York, Surgeon and Curator to BeUemu Hosp. 
In one very handsome roval 12ino. volume 

2.50. 
every student should possess one. This work 
does away with the necessity of pondering over 
larger works on surgery for descriptions of opera- 
tions, as it presents in a nutshell what is wanted 
bv the surgeon without an elaborate search to 
find \i.— Maryland Medical Journal, August, 1878. 



Henry C. Lea's Son & Co.'s Publications — Siirg-ery. 



21 



BUYAJSTT, THOMAS, F. M. C. S., 

Surgeon to Guy's Hospital, London. 
The Practice of Surgery. Third American from the third and revised English 
edition. Thoroughly revised and much improyed, by John B. Egberts, A. M., M. D., 
Lecturer on Anatomy and Operative Surgery in the Philadelphia Academy of Surgery. 
In one large and very handsome imperial octavo volume of 1009 pages, with 735 illustra- 
tions. Cloth, 16.50; leather, $7.50; very handsome half Pussia, raised bands, $8.00. 

plans of treatment, etc., to make the surgeon who 
follows the text suc'cessful in his diagnosis and 



Without freigliting his book with multiplied de- 
tails and wearying descriptions of allied methods 
of procedure, he is ample enough for reference on 
all the departments of surgery, not omitting such 
strict speciaUies as dental, ophthalmic, military, 
orthopjedic and gynaecological surgery. Some of 
these chapters are written by specialists in these 
respective branches, and all are amply sufficient 
for anyone not himself aiming at special practice. 
The labors of the American editor deserve un- 
qualified praise. His additions to the author's 
text are numerous, judicious and germane. They 
add very distinctly to the value of the original 
treatise, and give a more equitable illustration of 
the part taken by American surgeons than the 
autlior was able to do. — Medical and Surgical Re- 
porter, Feb. 12, 1881. 

It is the best of all the one-volume works on sur- 
gery of recent date for the ordinary sui'geon, con- 
taining enough of pathology, accurate description 
of surgical diseases and injuries, well-devised 



treatment in any case in which success can be se- 
cured, according to the present state of the sur- 
gical art. — Virginia Medical Monthly, May, 1881. 

It is a work especially adapted to the wants of 
students and practitioners. It affords instruction 
in sufficient detail for a full understanding of sur- 
gical principles and the treatment of surgical dis- 
eases. It embraces in its scope all tlie diseases 
tliat are recognized as belonging to surgery, and 
all traumatic injuries. In discussing these''it has 
seemed to be the aim of the author ratlier to pre- 
sent the student with practical information, and 
that alone, than to burden his memory with the 
views of different writers, however distinguished 
they might have been. In this edition the whole 
work has been carefully revised, much of it has 
been rewritten, and important additions have been 
made to almost every chapter. — Cincinnati Medical 
News, Jan. 1881. 



BMICMSJEW, JOmsr M, F. M. S., F. M. C. S., 

Professor of Surgery in University College, London, etc. 

The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, Dis- 
eases and Operations. Specially revised by the Author from the eighth and enlarged 
English edition. In two large and beautiful octavo volumes of about 2000 pages, illus- 
trated with about 900 engravings on wood. Preparing. 
A few notices of the previous edition are appended. 

His polished, clear style, his freedom from pre- 
judice and hobbies, his unsurpassed grasp of his 
subject and vast clinical experience, qualify him 
admirably to write a model text-book. When we 
wish, at the least cost of time, to learn the most of 
a topic in surgery, we turn, by preference, to his 
work. It is a pleasure, therefore, to see that the 
appreciation of it is general. — Medical and Surgical 
Reporter, Feb. 2, 1878. 

For the past twenty years Erichsen's Surgery 
has maintained its place as the leading text-book, 



not only in this country, but in Great Britain. 
That it is able to hold its ground is abundantly 
proven by the thoroughness vi'ith wliich the pres- 
ent edition has been revised, and by the large 
amount of valuable material that has been added. 
Aside from this, one hundred and fifty new ilkts- 
trations have been inserted, including quite a 
number of microscopical appearances of patholo- 
gical processes. So marked is this change for the 
better that the work almost appears as an entirely 
new one. — Medical Record, Feb. 23, 1878. 



ESMAMCM, JDr. FBIEDMICM, 

Professor of Surgery at the University of Kiel, etc. 

Early Aid in Injuries and Accidents. Five Ambulance Lectures. Tran8- 
lated by H. P. H. Princess Christian. In one handsome small 12mo. volume of 109 



pages, with 24 illustrations. Cloth, 75 cents. 

The excellent little handbook by Dr. Esmarch 
may be referred to by all for clear, safe and practi- 
cal directions and instructions for rendering the 
right kind of aid until the doctor arrives, in the 
event of the numerous injuries that are liable to 
happen in a family or neighborhood in the circum- 
stances of daily life. The manual is earnestly 
andjustly commended for its excellence and clear- 
ness, and especially for the minuteness and extent 
of its practical details. — Harpers' Magazine, Aug., 
188:5. 

The course of instruction is divided into five 
sections or lectures. The first, or introductory 
lecture, gives a brief account of the structure and 



Just ready. 

organization of the human body, illustrated by 
clear, suitable diagrams. The second teaches how 
to give judicious help in ordinary injuries — contu- 
sions, wounds, hfemorrhage and poisoned wounds. 
The third treats of first aid in cases of fracture 
and of dislocations, in sprains and in burns. Next, 
the methods of affording first treatment in cases 
of frost-bite, of drowning, of sutlbcation, of loss of 
consciousness and of poisoning are described; 
and the fifth lecture toaehos how injured persons 
may be most safely and easily transnorted to their 
hoiiies, to a medical man, or to a liospital. The 
illustrations in the book are clear and good. — Mali- 
cal Times and Gazette, Nov. 4. 1SS2. 



DBUITT, MOBFUT, M. M. C. S., etc. 

The Principles and Practice of Modern Surgery. From the eighth 
London edition. In one 8vo. volume of 687 pages, with 432 illus. Cloth, ;?4; leather, ;?5. 



SA RGENT ON BANDAGING and OTHER OPERA- 
TIONS OF MINOR SURGERY. New edition, 
with a Cliaptcr on military surgery. One VJmo. 
volume of ;58:5 pages, with 187 cuts. Cloth, $\.':5. 

MILLER'S PRINCIPLES OF SURGERY. Fourth 
American from the third Edinburgh edition. In 
one 8vo. vol. of ()88 pages, with aU) il lust rations. 
Cloth, $15.75. 

MILLER'S PRACTICE OF SURGERY. Fourth 
and revised American from the last Edinburgh 
edition. In one largo 8vo. vol. of GS'2 pages, with 
8(14 illuetrations. Cloth, S3.75. 



PIRRIE'S PRINCIPLES AND PRACTICE OP 
SURGERY. Edited bv John Nkii.l, M. D. In 
one Svo. vol. of 784 pp. with ;Uii illus. Cloth, S;'>.75. 

COOPER'S LECTURES ON THE PRINCIPLES 
AND PRACTICE OF SURGERY. In one 8vo.vol. 

of 7tM pages. Cloth, Sl'.OO. 

SKEY'S OPERATIVE SURGERY. In oneTol.S>'<v 
of (U!l pages, with 81 woodcuts. Cloth, S;>.-2"\ 

GIPSON'S INSTITUTES AND PRACTICE OP 
SURGERY. Eighth edition. In two octavo toI*. 
of i)()5 pages, with 34 plates. Leather St>.50. 



22 Henry C. Lea's Son & Co.'s Publications — Sm-gery. 

HOLMES, TIMOTHY, 31. A., 

Surgeon and Lecturer on Surgery at St. George's Hospital, London. 

A System of Surgery ; Theoretical and Practical. IN TKEATISES BY 
VAKIOUS AUTHOES. American edition, thoroughly re^t:sed and re-edited 
by John H. Packard, M. D., Surgeon to the EjDiscopal and St. Joseph's Hospitals, 
Philadelphia, assisted bv a corps of thirty-three of the most eminent American surgeons. 
In three large and very handsome imperial octavo volumes containing 3137 double- 
columned pages, with 979 illustrations on wood and 13 lithographic plates, beautifully 
colored. Price per volume, cloth, 56.00 ; leather, $7.00 ; half Kussia, $7.50. Per set, cloth, 
$18.00 ; leather, $21.00 ; half Kussia, $22.50. Sold only by subscription. 

VoLusiE I. contains General Pathology, Morbid Processes, Injuries in Gen- 
eral, Complications of Injuries and Injuries of Eegions. 

Volume II. contains Diseases of Organs of Special Sense, Circulatory Sys- 
tem, Digestive Tract and Genito-Urinary Organs. 

Volume III. contains Diseases of the Kespiratory Organs, Bones, Joints and 
Muscles, Diseases of the Xeryous System, Gunshot Wounds, Operative and 
Minor Sltigery, and Miscellaneous Subjects (including an essay on Hospitals). 

This great work, issued some years since in England, has won such universal confi- 
dence wherever the language is spoken that its republication here, in a form more 
thoroughly adapted to the wants of the American practitioner, has seemed to be a duty 
owing to the profession. To accomplish this, each article has been placed in the hands of 
a gentleman specially competent to treat its subject, and no labor has been spared to bring 
each one up to the foremost level of the times, and to adapt it thoroughly to the practice 
of the country. In certain cases this has rendered necessary the substitution of an entirely 
new essay for the original, as in the case of the articles on Skin Diseases and on Diseases 
of the Absorbent System, where the views of the authors have been superseded by the 
advance of medical science, and new articles have therefore been prepared by Drs. Arthur 
Van Harlingen and S. C. Busey, respectively. So also in the case of Ansesthetics, in the use 
of which American practice differs from that of England, the original has been supple- 
mented with a new essay by J. C. Peeve, M. D. The same careful and conscientious 
revision has been pursued throughout, leading to an increase of nearly one-fourth in 
matter, while the series of illustrations has been nearly trebled, and the whole is presented 
as a complete exponent of British and American Surgery, adapted to the daily needs of 
the working practitioner. 

In order to bring it within the reach of every member of the profession, the five vol- 
umes of the original have been compressed into three by employing a double-columned 
royal octavo page, and in this improved form it is offered at less than one-half the price of the 
original. It is printed and bound to match in every detail with Reynolds' System of Medi- 
cine. The work will be sold by subscription only, and in due time every member of the 
profession will be called upon and offered an opportunity to subscribe. 

The authors of the original English edition are > Great credit is due to the American editor and 
men of the front rank in England, and Dr. Packard ; his co-laborers for revising and bringing within 
has been fortunate in securing as his American easy reach of Amei'ican surgeons a work vvhicla has 
■jutors such men as Bartholow, Hyde, Hunt, , been received with such universal favor on the 



Conner, Stimson, Morton, Hodden, Jewell and , other side of the Atlantic as Holmes' System of 

their colleagues. As a whole, the work will be Surgery. With regard to the mechanical execu- 

solid and substantial, and a valuable addition to tion of the work, neither pains nor money seem 

the library of any medical man. It is more wieldly to have been spared by the publishers. — 3Ied. and 

and more'useful than the English edition, and with Surg. Heporter, Sept. 14, 1881. 

its companion work-" Reynolds' Systern of Medi- j^ ^^^ revision of the work for the American 

cine -will well represent the present state of our ^^^^^^,^ ^.^t onlv has provision been made for a 

science One who is familiar with th9se two works recognition of the advances made in our knowledge 

will befairly well furnished head-wise and hand- : ^^^.^^ ^j.^ ^^^ ..^^^.g ^^^^^^ j^, ^^^^ publication, 

wise.-The3Tedical]\eu:s,JaTi.7,1882. • ^^^ also for a presentation of the variations in 

This work is cyclopaedic in character, and every practice which characterize American surgery and 

subject is treated in an exhaustive manner. It is distinguish it from that of Great Britain. The 

especially designed for a reference book, which work is one which we take pleasure in com- 

every practising surgeon should have under hand mending to the notice of our readers as an ency- 

in cases which require more than ordinary knowl- clopsedia of surgical knowledge and practice. — 

edge. — Chicago Med. .Journ. and Exam., Feb. 1882. St. Louis Courier of Medicine, Nov. 1881. 



HAMILTOJS^, FUAJSIS: H., 31. D., LL. !>., 

Surgeon to Bellevue Hospital, New York. 

A Practical Treatise on Fractures and Dislocations. Sixth edition, 
thoroughly revised and much imiDroved. In one very handsome octavo volume of 909 
pages, with 352 illustrations. Cloth, $5.50 ; leather, §6.50 ; half Eussia, raised bands, $7.00. 

The only complete work on its subject in j work in his own or any language on fractures and 

the English tongue, and indeed it may now be dislocations. — Lond. Med. Times and Gaz.'!Soy. 19, '81. 

said to be the only work of its kind in any j The work as a whole is one of the very few 

tongue. It would require an exceedingly critical i medical books of American origin that are every- 

examination to detect in it any particulars in where accorded a standard character, its sub- 

which it might be improved. The work is a mon- ject-matter unavoidablv comes home to every 

umentto American surgery, and will long serve to general practitioner as a branch of our art in 

keep green the memory of its venerable author.— which he cannot afford to neglect the fullest and 

Michigan Medical News, Nov. 10, 1881. . most practical information of such a character as it 

Dr. Hamilton is the author of the best modern ' and it alone furnishes. — N. Y. Med. Jour., March.'Sl. 



Henry C. Lea's Son & Co.'s Publications — Frac, Bisloc, Ophthal. 23 



8TIMSOW, LJEWIS A., B. A., M. J)., 

Professor of Pathological Anatomy at the University of the City of New York, Surgeon and Curator 
to Bellevue Hospital, Surgeon to the Presbyterian Hospital, New York, etc. 

A Practical Treatise on Fractures. In one very handsome octavo volume of 
598 pages, with 360 beautiful illustrations. Cloth, $4.75 ; leather, $5.75. 

The author has given to the medical profession 



The author gives in clear language all that the 
practical surgeon need know of the science of 
fractures, their etiology, symptoms, processes of 
union, and treatment, according to the latest de- 
velopments. On the basis of mechanical analysis 
the author accurately and clearly explains the 
clinical features of fractures, and by the same 
method arrives at the proper diagnosis snd rational 
treatment. A thorough explanation of the patho- 
logical anatomy and a careful description of the 
various methods of procedure make the book full 
of value for every practitioner. The diction is 
simple, clear and vivid. Wherever desirable, brief 
clinical histories are introducted, which, being 
skillfully chosen to illustrate particular points, 
attest the rich experience of the author. The 
numerous beautifully-executed illustrations form 
an especial attraction of the book. — Gentralhlatt 
fur Chirurgie, May 19, 1883. 



in this treatise on fractures what is likely to be- 
come a standard work on the subject. It is certainly 
not surpassed by any work written in the English, 
or, for that matter, any other language. The au- 
thor tells us in a short, concise and comprehensive 
manner, all that is known about his subject. There 
is nothing scanty or superficial about it, as in most 
other treatises ; on the contrary, everything is thor- 
ough. The chapters on repair of fractures and their 
treatment show him not only to be a profound stu- 
dent, but likewise a practical surgeon and patholo- 
gist. His mode of treatment of tlie different fract- 
ures is eminently sound and practical. We consider 
this work one of the best on fractures ; and it will 
be welcomed not only as a text-book, but also by 
the surgeon in full practice. — N. O. Medical and 
Surgical Journal, March, 1883. 



WBLLS, J. SOBLBJEMG, F. M. C. S., 

Professor of Ophthalmology in King''s College Hospital, London, etc. 

A Treatise on Diseases of the Eye. Fourth American'from the third London 
edition. Thoroughly revised, with copious additions, by Charles S. BulI;, M. D., Surgeon 
and Pathologist to the New York Eye and Ear Infirmary. In one large and very hand- 
some octavo volume of 822 pages, with 257 ilhistrations on wood, six colored plates, and 
selections from the Test-types of Jaeger and Snellen. Cloth, $5.00 ; leather, $6.00 ; 
very handsome half Russia, raised bands^ $6.50. Just ready. 

The present edition appears in less than three 
years since the publication of the last American 
edition, and yet, from the numerous recent inves- 
tigations that have been made in this branch of 
medicine, many changes and additions have been 
required to meet the present scope of knowledge 
upon this subject. A critical examination at once 
snows the fidelity and thoroughness with which 
the editor has accomplished his part of the work. 
The illustrations throughout are good. This edi- 
tion can be recommended to all as a complete 
treatise on diseases of the eye, than which proba- 
bly none better exists. — Medical Record, Aug. 18, '83. 

This magnificent work is par excellence the 
standard work of the times on the important sub- 
jects of which it treats. It is absolutely necessary 
for the physician to have an acquaintance with the 
pathology and therapeutics of the eye. From no 
source can he more accurately derive this needed 
knowledge than from the volume before us. — 
Medical and Surgical Reporter, August 4, 1883. 

Anj'one desirous of obtaining the most com- 



plete work on diseases of the eye in the English 
language, will find in this treatise the fulfilment 
of that desire. Dr. Bull's additions to the volume 
may be taken as a brief but very excellent r^sumi 
of the progress made in ophthalmology during 
the past ten years. It is no exaggeration to say- 
that there are few more readable books in medi- 
cine than this; certainly no medical library can 
be considered complete without it.— Canada Medi- 
cal and Surgical Journal, November, 1883. 

The issue of a fourth American edition of this 
work within three years of the third, shows how 
favorably it has been received by the medical pro- 
fession at large. We must congratulate the editor 
on his clearness and conciseness in laying down 
rules for treatment and the proper remedies to be 
used in every case. This work must be pro- 
nounced the most complete text-book on the sub- 
ject, and merits careful perusal bj' the student as 
well as the practitioner, while to the specialist it 
will be found an easy and faithful book of refer- 
ence. — Cincinnati Lancet and Clinic, August 18, 1838. 



NJETTLBSHIJP, JEDWABD, F. M. C. S., 

Ophthalmic Surg, and Lect. on Ophth. Surg, at St. Thomas' Hospital, London. 

The Student's Guide to Diseases of the Eye. New edition. With a chap- 
ter on the Detection of Color-Blindness, by William Thomson, ^L D., Ophthalmologist 
to the Jefferson Medical College. In one royal 12mo. volume of 416 pages, with 138 
illustrations. Cloth, $2.00. Just ready. 



This admirable guide bids fair to become the 
favorite text-book on ophthalmic sni'gery with stu- 
dents and general practitioners. It be.irs through- 
out the imprint of sound judgment combined with 
vast experience. The illustrations are numerous 
and well chosen. This book, within the short com- 
pass of about 400 pages, contains a lucid exposition- 
of tho modern aspect of ophthalmic science. — 
Medical Record, June 23, 1883. 

This work is essentially a student's manual of 
ophthalmology, and the favor with which it has 



been received shows its real value and the appre- 
ciation by the profession of its intrinsic merits. 
Dr. Thomson has added a Chapter on t^olor- Blind- 
ness, on which subject his extensive investigations 
are well known. \Vith this valuable addition the 
book becomes tlie most valnable guide to diseases 
of the eye yet published. Wo commend it to the 
notice o'i students of mediinne, and to suci\ prae- 
titioners as desire a condensed treatise on a olai'S 
of diseases which are frequently met with in daily 
practice. — Buffalo Med. ami Surg. Journ., May. 1883. 



BllOWWF, FJDGAB A., 

Surgeon to the Liverpool Eye and Ear Infirmary and to the Dispensary for Skin Diseases. 
How to Use the Ophthalmoscope. Being Elementary Instructions in (^ph- 
thalrnoaoopy, arranged for the use of Students. In one small royal 12mo, volume of 116 
pages, with 35 illustrations. Cloth, $1.00. 

LAWSON ON INJURIES TO THE EVE, ORBIT I titioners. Second edition. In one octavo vol- 
ANI> EYELIDS: Their ImnuHliate and Remote ume of 2'27 pages, with Oo illnst. Cloth. S-J.V.V 
Elh>.n.s. 8 vo., 404 pp., iVi iUus. Cloth, $?.r>0. CARTER'S RKACTlCATi TREATISE ON niSE.\S- 

LAURICNCE AND ISIOON'S lIANin' ROOK OF | ES OF THE EVE. Edited bv John GKiiKN, M.D- 
OPHTHALMIC SURGERY, for the use of Prac- i In one handsome octavo volun\e. 



24 Henry C. Lea's Son & Co.'s Publications — Otol., Dent.,Urm. Dis. 



I'OLITZJEB, ADAM, 

Imperial-Royal Prof, of Aural Therap. in the Univ. of Vienna. 

A Text-Book of the Ear and its Diseases. Translated, at the Author's re- 
quest, by James Patterson Cassells, M. D., M. E. C. S. In one handsome octavo vol- 
ume of 800 pages, with 257 original illustrations. Cloth, $5.50. Jiisi ready. 

Professor Politzer's well-known reputation as one 
of the first authorities on diseases of the ear will 
'ead the reader to expect something more than an 
ordinary text-book in a work that bears his name, 
and he will not be disappointed. The anatomy, 
physiology, pathology, therapeutics and bibli- 



ography of the ear are so ably and thorouglilj'- pre- 
sented, that he who has carefully read tliis imposing 
volume can feel sure that very little of interest or 
value in the past or present of aural surgery has 
escaped him, — Am. Jour, of the Med. Sciences, July, 
1883. 
The work itself we do not hesitate to pronounce 



has ever appeared, systematic without being too 
diffuse on obsolete subjects, and eminently prac- 
tical in every sense. The anatomical descriptions 
of each separate division of the ear are admirable, 
and profusely illustrated by woodcuts. They are 
followed immediately by the physiology of the 
section, and this again by the pathological physi- 
ology, an arrangement wliich serves to keep up the 
interest of the student by showing the direct ap- 
plication of what has preceded to the study of dis- 
ease. The whole work can be recommended as a 
reliable guide to the student, and an efficient aid 
to the practitioner in his treatment. — Boston Med- 



the best upon the subject of aural diseases which I cal and Surgical Journal, June 7, 1883. 



BVMNETT, CMAMLBS M., A. 31., 31. D., 

Aural Surg, to the Fresh. Hosp., Surgeon-in-charge of the Infir.for Dis. of the Ear, Philadelphia. 

The Ear, Its Anatomy, Physiology and iDiseases. A Practical Treatise 
for the use of Medical Students and Practitioners. New edition. In one handsome octavo 
volume of about 700 pages, with about 100 illustrations. 

A notice of the previous edition is appended. 
The medical profession will welcome this duced a work which, as a text-book, stands facile 
work on otology, which presents clearly and con- princeps in our language. To the specialist the 
eisely its present aspect, whilst clearly 'indicating work is of the highest value. — Edinburgh Med. Jour ^ 
the direction in which further researches can be Aug. '78. 
most profitably carried on. Dr. Burnett has pro- 



COLB3IAW, A., L. M. C. JP., F. M. C. S., JExam. L. D. S., 

Senior Dent. Surg, and Lect. on Dent. Surg, at St. Bartholomew's Hosp. and the Dent. Hosp., London. 

A Manual of Dental Surgery and Pathology. Thoroughly revised and 
adapted to the use of American Students, by Thomas C. Stellwagen, M. A., M. D., 
D. D. S., Prof, of Physiology at the Philadelphia Dental College. In one handsome octavo 
volume of 412 pages, with 331 illustrations. Cloth, |3.25. 

This volume deserves to rank among the most I deserves a place in the library of every dentist. 
Important of recent contributions to dental litera- | — Dental Cosmos, May, 1882. 
ture. Mr. Coleman has presented his methods of I It should be in the possession of every practi- 



practice, for the most part, in a plain and concise 
manner, and the work of the American editor has 
been conscientiously performed. He has evidently 
labored to present his convictions of the best modes 
of practice for the instruction of those commenc- 
ing a professional career, and he has faithfully en- 
deavored to teach to others all that he has acquired 
by his own observation and experience. The book 



tioner in this country. The part devoted to first 
and second dentition and irregularities in the per- 
manent teeth is fully worth tiie price. In fact, 
price should not be considered in purchasing such 
a work. If the money put into some of our so-called 
standard text-books could be converted into such 
publications as this, much good would result. — 
Southern Dental Journal, May, 1882. 



GMOSS, S. JD., 31. D., LL. D., J}. C. L., etc. 

A Practical Treatise on the Diseases, Injuries and Malformations 
of the Urinary Bladder, the Prostate Gland and the Urethra. Third 

edition, thoroughly revised by Samuel W. Gross, M. D., Surgeon to the Philadelphia 
Hospital. In one octavo volume of 574 pages, with 170 illustrations. Cloth, $4.50. 

For reference and general information, the phy- sual advantage of being easily com.prehended by-~--__ 

the reasonable and practical manner in which the 
various subjects are systematized and arranged- 
— Atlanta Medical Journal, Oct., 1876. 



flician or surgeon can find no worli that meets their 
necessities more thoroughly than this, a revised 



edition of an excellent treatise. Replete with hand- 
some illustrations and good ideas, it has the unu- 



ROBJEHTS, WILLIA3I, 31. JO., 

Lecturer on Medicine in the Manchester School of Medicine, etc. 

A Practical Treatise on Urinary and Renal Diseases, including Uri- 
nary Deposits. Fourth American from the fourth London edition. Illustrated by 
numerous engravings. In one large and handsome octavo volume. Preparing. 

TII03irS0N, SIM JELBJSBY, 

Surgeon and Professor of Clinical Surgery to University College Hospital, London. 

Lectures on Diseases of the Urinary Organs. Second American from the 
third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. 

By the Same Author. 

On the Pathology and Treatment of Stricture of the Urethra and 
Urinary FistulEe. From the third English edition. In one volume of 359 pages, with 
47 cuts and 3 plates. Cloth, |3.50. 

of 304 pages, with 21 illustrationa 



BASHAM on renal DISEASES: A Clinical 
Guide to their Diagnosis and Treatment. In 



one 12mo. vol. 
Cloth, $2.00. 



Henry C. Lea's Son & Co.'s Publications — Venereal Dis., etc. 25 



BVMSTBAJy, F. J., 

Late Professor of Venereal Diseases 
at the College of Physicians and 
Surgeons, New York, etc. 



and TAYLOM, H. TF., 

A. M., M. D., 

Surgeon to Charity Hospital, New York, Prof, of 
Venereal and Skin Diseases in the University o] 
Vermont, Pres. of the Am. Dermatological Ass'n. 

The Pathology and Treatment of Venereal Diseases. Including the 
results of recent investigations upon the subject. Fifth edition, revised and largely re- 
written, by Dr. Taylor. In one large and handsome octavo volume of about 898 pages 
with 139 illustrations, and thirteen chromo-lithographic figures. Cloth, $4.75 ; leather, 
$5.75 ; very handsome half Kussia, $6.25. 

Excerpt from the Preface to the Fifth Edition. 

In this edition I have carefully revised the text, and, when necessary, have changed 
and modified it, and I have endeavored to bring it up to our present state of knowledge in 
all particulars. Much new matter will be found relating to therapeutics, and a chapter 
on syphilis and marriage has been appended. 



This admirable book is undoubtedly the best 
book on the subject which has appeared on this 
side of the Atlantic, and one of the best which has 
appeared anywhere. As years have rolled by it 
has reached successive editions, constantly assimi- 
lating the conclusions of scientific investigations 
all over the world, and never falling behind the 
advance guard of its own department. This last 
edition keeps up tne reputation which its prede- 
cessors required. It comes revised, added to and 
improved. It is in every way admirable, a credit 
to its authors and a credit to its publishers. — The 
Medical Neivs, Dec. 22, 1883. 

The character of this standard work is so well 



known that it would be superfluous here to pass in 
review its general or special points of excellence. 
The verdict of the profession has been passed; it 
has been accepted as the most thorough and com- 
plete exposition of the pathology and treatment of 
venereal diseases in the language; admirable as a 
model of clear description, an exponent of sound 
pathological doctrine, and a guide for rational and 
successful treatment, it is an ornament to the medi- 
cal literature of this country. The additions made 
to the present edition <are eminently judicious, 
from the standpoint of practical utility. — Journal of 
Cutaneous and Venereal Diseases, Jan. 1884. 



COMJSfIL, v., 

Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hospital. 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially 
revised by the Author, and translated with notes and additions by J. Henry C. Simes, 
M. D., Demonstrator of Pathological Histology in the University of Pennsylvania, and 
J. William White, M. D., Lecturer on Venereal Diseases and Demonstrator of Surgery 
in the University of Pennsylvania. In one handsome octavo volume of 461 pages, witn 

Just ready. 
the whole volume is the clinical experience of the 
author or the wide acquaintance of the translators 
with medical literature more evident. The anat- 
omy, the histology, the pathology and the clinical 
features of syphilis are represented in tliis work in 
their best, most practical and most instructive 
form, and no one will rise from its perusal without 
the feeling that his grasp of the wide and impor- 
tant subject on which it treats is a stronger and 
surer one. — The London Practitioner, Jan. 1882. 



84 very beautiful illustrations. Cloth, $3.75. 
The anatomical and histological characters of the 
hard and soft sore are admirably described. The 
multiform cutaneous manifestations of the disease 
are dealt with histologically in a masterly way, as 
we should indeed expect them to be, and the 
accompanying illustrations are executed carefully 
and well. The various nervous lesions which are 
the recognized outcome of the syphilitic dyserasia 
are treated with care and consideration. Syphilitic 
epilepsy, paralj^sis, cerebral syphilis and locomotor 
ataxia are subjects full of interest; and nowhere in 



GBOS8, SAMJJBL W., A. M., M. !>., 

Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College. 

A Practical Treatise on Impotence, Sterility, and Allied Disorders 
of the Male Sexual Organs. Second edition, thoroughly revised. In one very hand- 
some octavo volume of 168 pages, with 16 illustrations. Cloth, $1.50. Just ready. 

The author of this monograph is a man of posi- 
tive convictions and vigorous style. Tliis is justi- 
fied by his experience and by his study, which has 
gone hand in hand with his experience. In regard 
to the various organic and functional disorders of 
the male generative apparatus, he has had ex- 
ceptional opportunities for observation, and his 
book shows that he has not neglected to compare 
his own views with those of other authors. The 
result is a work which can be safely recommended 
to both physicians and surgeons as a guide in the 
treatment of the disturbances it refers to. It is 
the best treatise on the subject with which we are 
acquainted.— T/ie Medical News, Sept. 1, 1883. 



This work will derive value from the high stand- 
ing of its author, aside from the fact of its passing 
so rapidly into its second edition. This is, indeed, 
a book tliat every physician will be glad to place 
in his librarj', to be read with profit to himself, 
and with incalculable benefit to his patient. Be- 
sides the subjects embraced in the title, which are 
treated of in their various forms and degrees, 
speiniatorrha\a and prostatorrho?a are also" fully 
considered. The work is thoroughly practical in 
character, and will be especiallv useful to the 
general practitioner.— i)/rt/(tai llccord, Aug. 18, 
18S;5. 



CULLBRIBB, A., & BTJMSTJEAI), 1\ J., J/.l>., LL.D., 

Surgeon to the HCpital du Midi. Late Professor of Venereal Diseases in the College of IViysicians 

and Surgeons, New York. 

An Atlas of Venereal Diseases. Translated and edited by Fkekman J. Rum- 
stead, M.D. In one imperial 4to. volume of o28 pages, double-columns, with il6 plates, 
containing about 150 figures, beautifully colored, numy of thorn the size o( life. Strongly 
bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 ets. 

HILT. ON SYPHILIS AND LOC.\L CONTAGIOUS t FORMS OF LOCAL DISEASE AFFECTING 

DlSOUDEllS. In one Svo vol. of 479 p. Cloth, $5.25. PRINCIPALLY THE ORGANS OF GENER,\- 

LEE'S LECTURES ON SYPHILIS AND SOME | TION. In one Svo. vol. of 216 pasxos. Cloih, S-J.iiS. 



26 Henry C. Lea's Son & Co.'s Publications — Diseases of Skin. 



STTDJE, J. NEVUS'S, A. 31., M. I)., 

Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. 

A Practical Treatise on Diseases of the Skin. For the use of Students and 
Practitioners. In one handsome octavo volume of 570 pages, with 66 beautiful and elab- 
orate illustrations. Cloth, §4.25 ; leather, §5.25. Just ready. 



The author has given the student and practi- 
tioner a work admirably adapted to the wants of 
each. We can heartily commend the book as a 
valuable addition to our literature and a reliable 
guide to students and practitioners in their studies 
and practice. — Am. Journ. of Med. Sci., July, 1883. 

Especially to be praised are the practical sug- 
gestions as" to what may be called the common- 
sense treatment of eczema. It is quite impossible 
to exaggerate the judiciousness with which the 
formuiie for the external treatment of eczema are 
selected, aud what is of equal importance, the full 
and clear instructions for their use. — London Medi- 
cal Times and Gazette, July 28, 1883. 

The work of Dr. Hyde will be awarded a high 
position. The student of medicine will find it 
peculiarly adapted to his wants. Notwithstanding 
the extent of the subject to which it is devoted, 
yet it is limited to a single and not verj' large vol- 
ume, without omitting a proper discussion of the 
topics. The conciseness of the volume, and the 
setting forth of only what can be held as facts will 
also make it acceptable to general practitioners. 
— Cincinnati Medical Nevjs, Feb. 1883. 

The aim of the author has been to present to his 
readers a work not only expounding the most 
modern conceptions of his subject, but presenting 
what is of standard value. He has more especially 
devoted its pages to the treatment of disease, and 
by his detailed descriptions of therapeutic meas- 
ures has adapted them to the needs of the physi- 



cian in active practice. In dealing with these 
questions the author leaves nothing to the pre- 
sumed knowledge of the reader, but enters thor- 
oughly into the most minute description, so that 
one is not only told what should be done under 
given conditions but how to do it as well. It is 
therefore in the best sense " a practical treatise." 
That it is comprehensive, a glance at the index 
will show. — Marijland Medical Journal, July 7, 1883. 
Professor Hyde has long been known as one of 
the most intelligent and enthusiastic representa- 
tives of dermatology in the west. His numerous 
contributions to the literature of this specialty 
have gained for him a favorable recognition as a 
careful, conscientious and original observer. The 
remarkable advances made in our knowledge of 
diseases of the skin, especially from the stand- 
point of pathological histology and improved 
methods of treatment, necessitate a revision of 
the older text-books at short intervals in order to 
bring them up to the standard demanded by the 
march of science. This last contribution of Dr. 
Hyde is an effort in this direction. He has at- 
tempted, as he informs us, the task of presenting 
in a condensed form the results of the latest ob- 
servation and experience. A careful examination 
of the work convinces us that he has accomplished 
his task with painstaking fidelity and with a cred- 
itable result. — Journal of Cutaneous and Venereal 
Diseases, June, 1883. 



FOX, T., M.D., F.JR. C. JP., and FOX, T. C, B.A., M.M. C.S., 

Physician to the Department for Skm Diseases, Physician for Diseases of the Skin to the 

University College Hospital, London. Westminster Hospital, London. 

An Epitome of Skin Diseases. With Formula. For Students and Prac- 
titioners. Third edition, revised and enlarged. In one very handsome 12mo. volume 
of 238 pages. Cloth, $] .25. JuM ready. 



The third edition of this convenient handbook 
calls for notice owing to the revision and expansion 
which it has undergone. The arrangement of skin 
diseases in alphabetical order, which is the method 
of classification adopted in this work, becomes a 
positive advantage to the student. The book is 
one which we can strongly recoinmend, not only 
to students but also to practitioners who require a 
compendious summary of the present state of 
dermatology. — British Medical Journal, July 2, 1883. 

We cordially recommend Fox's Epitome'to those 
whose time is limited and who wish a handy 



manual to lie upon the table for instant reference. 
Its alphabetical arrangement is suited to this use, 
for all one has to know is the name of the disease, 
and here are its description and the appropriate 
treatment at hand and ready for instant applica- 
tion. The present edition has been very carefully 
revised and a number of new diseases are de- 
scribed, while most of the recent additions to 
dermal therapeutics find mention, and the formu- 
lary at the end of the book has been considerably 
augmented. — The Medical News, December, 1883. 



MOMHIS, MALCOLM, M. n.. 

Joint Lecturer on Dermatology at St. Mary's Hospital Medical School, London. 
Skin Diseases ; Including their Definitions, Symptoms, Diagnosis, Prognosis, Mor- 
bid Anatomy and Treatment. A Manual for Students and Practitioners. In one 12mo. 
volume of 316 pages, with illustrations. Cloth, ^1.75. 

To phj'-sicians who would like to know something i for clearness of expression and methodical ar- 
about skin diseases, so that when a patient pre- j rangement is better adapted to promote a rational 
sents himself for relief they can make a correct , conception of dermatology — a branch confessedly 



diagnosis and prescribe a rational treatment, we 
unhesitatingly recommend this little book of Dr. 
Morris. The affections of the skin are described 
in a terse, lucid manner, and their several charac- 
teristics so plainly set forth that diagnosis will be 
easy. The treatment in each case is such as the 
experience of the most eminent dermatologists ad- 
vises. — Cincinnati Medical JVews, April, 1880. 

This is emphatically a learner's book; for we 
can safely say, that in the whole range of medical 
literature there is no book of a like scope which 



difficult and perplexing to the beginner. — St. Louis 
Courier of Medicine, April, 1880. 

The writer has certain!}^ given in a small compasa 
a large amount of well-compiled information, and 
his little book compares favorably with any other 
which has emanated from England, while in many 
points he has emancipated himself from the stub- 
bornly adhered to errors of others of his country- 
men. There is certainly excellent material in tne 
book which will well repay perusal. — Boston Med. 
and Surg. Journ., March, 1880. 



WILSON, FMAS3IUS, F. B. S. 

The Student's Book of Cutaneous Medicine and Diseases of the Skin. 

In one handsome small octavo volume of 535 pages. Cloth, $3.50. 

BLLLIFB, TH03IAS, 3L !>., 

Physician to the Skin Department of University College, London. 
Handbook of Skin Diseases ; for Students and Practitioners. Second Ameri- 
can edition. In one 12mo. volume of 353 pages, with^pla,tes. Cloth, $2.25. 



Henry C. Lea's Son & Co.'s Publications — ^Dis. of Women. 



27 



AW A3IJEBICAW SYSTEM OF GTWJECOLOGT. 

A System of Gynaecology, in Treatises by Various Authors. In two 

handsome octavo volumes , richly illustrated. In active preparation. 

LIST OF CONTRIBUTORS. 



FORDYCE BARKER, M. D., 
ROBERT BATTEY, M. D., 
SAMUEL C. BUSEY, M. D., 
HENRY F. CAMPBELL, M. D., 
BENJAMIN F. DAWSON, M. D., 
WILLIAM GOODELL, M. D., 
HENRY F. GARRIGUES, M. D., 
SAMUEL W. GROSS, M. D., 
JAMES B. HUNTER, M. D., 
WILLIAM T. HOWARD, M. D., 
A. REEVES JACKSON, M. D., 
EDWARD W. JENKS, M. D., 

WILLIAM H. 



CHARLES CARROLL LEE, M. D., 
WILLIAM T. LUSK, M. D., 
MATTHEW D. MANN, M. D., 
ROBERT B. MAURY, M. D., 
C. D. PALMER, M. D., 
WILLIAM M. POLK, M. D., 
THADDEUS A. REAMY, M. D., 
A. D. ROCKWELL, M. D., 
ALBERT H. SMITH, M. D., 
R. STANSBURY SUTTON, A. M., M. D. 
T. GAILLARD THOMAS, M. D., 
CHARLES S. WARD, M. D., 
WELCH, M. D. 



TMOMAS, T. GAIZLAMD, M. 2>., 

Professor of Diseases of Women in the College of Physicians and Surgeons, N. Y. 

A Practical Treatise on the Diseases of Women. Fifth edition, thoroughly 
revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266 
illustrations. Cloth, $5.00 ; leather, $6.00 ; very handsome half Russia, raised bands, $6.50. 



The words which follow " fifth edition" are in 
this ease no mere formal announcement. The 
alterations and additions which have been made are 
both numerous and important. The attraction 
and the permanent character of this book lie in 
the clearness and truth of the clinical descriptions 
of diseases; the fertility of the author in thera- 
peutic resources and the fulness with which the 
details of treatment are described; the definite 



character of the teaching; and last, but not least, 
the evident candor which pervades it. We would 
also particularize the fulness with which the his- 
tory of the subject is gone into, which makes the 
book additionally interesting and gives it value as 
a work of reference. — London Medical Times and 
Gazette, July 30, 1881. 

The determination of the author to keep his 
book foremost in the rank of works on gynaecology 
is most gratifying. Recognizing the fact that this 
can only be accomplished by frequent and thor- 

ougn revision, he has spared no pains to make the I cent improvements in treatment, 
present edition more desirable even than the pre- ! and Surgical Journal, Jan. 1881 



vious one. As a book of reference for the busy 
practitioner it is unequalled. — Boston Medical and 
Surgical Journal, April 7, 1880. 

It has been enlarged and carefully revised. It is 
a condensed encyclopeedia of gynaecological medi- 
cine. The style of arrangement, the masterly 
manner in which each subject is treated, and the 
honest convictions derived from probablj?^ the 
largest clinical experience in that specialty of any 
in this country, all serve to eomm.end it in the 
highest terms to the practitioner. — Nashville Jour. 
of Med. and Surg., Jan. 1881. 

That the previous editions of the treatise of Dr. 
Thomas were thought worthj^ of translation into 
German, French, Italian and Spanish, is enough 
to give it the stamp of genuine merit. At home it 
has made its way into the library of every obstet- 
rician and gynaecologist as a safe guide to practice. 
No small number of additions have been made to 
the present edition to make it correspond to re- 

Pacific Medi-cal 



JEDIS, ABTMUM W., M. D., Land., F.M. C.JP., M.B. C.S., 

Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital. 
The Diseases of Women. Including their Pathology, Causation, Symptoms, 
Diagnosis and Treatment. A Manual for Students and Practitioners. In one handsome 
octavo volume of 576 pages, with 148 illustrations. Cloth, $3.00 ; leather, $4.00. 

It is a pleasure to read a book so thoroughly The greatest pains have been taken with the 
good as this one. The special qualities which are sections relating to treatment. A liberal selection 
conspicuous are thoroughness in covering the of remedies is given for each morbid condition, 
whole ground, clearness of description and con- the strength, mode of application and other details 
ciseness of statement. Another marked feature of being fully explained. The descriptions of gj'nae- 
the book is the attention paid to the details of | cological manipulations and operations are full. 



many minor surgical operations and procedures, 
as, for instance, the use of tents, application of 
leeches, and use of hot water injections. These 
are among the more common methods of treat- 
ment, and yet very little is said about them in 
many of the text-books. The book is one to be 
warmly recommended especially to students and 
general practitioners, who need a concise but com- 
plete resume, of the whole subject. Specialists, too, 
will find many useful hints in its pages. — Boston 
Med. and Surg. Journ., March 2, 1882. 



clear and practical. IMueh care has also been be- 
stowed on the parts of the book which deal with 
diagnosis — we note especially the pages dealing 
with tlie ditterentiation, one from another, of the 
ditferent kinds of abdominal tumors. Tlie prac- 
titioner will therefore find in this book the liind 
of knowledge he most needs in his daily work, and 
he wili be pleased with the clearness and fulness 
of the information there given. — The J^-actitiouer, 
Feb. 1882. 



BAUWBS, MOBBBT, 31. D., F. JR. C. F., 

Obstetric Physician to St. Thomas'' Hosriital, London, etc. 

A Clinical Exposition of the Medical and Surgical Diseases of Women. 

In one handsome octavo volume, with numerous illustrations. New edition. Preparing. 

CHAnWICK, JA3IFS Jl.,A. M., 31. h. 

A Manual of the Diseases Peculiar to Women. In one handsome royal 
12mo. volume, with illustrations. Preparing. 

WFST, CHABLFS, 31. JX 

Lectures on the Diseases of Women. Third American from the third Lon- 
don edition. In one octavo volume of 548 pages. Cloth, $3.75 ; leather, $4.75. 



2S Hexky C. Lea's Son & Co.'s Publications — Ois. of Women, 3Iidwfy. 

i:jijii:t, tsojias addis, ji. n., zz. z>., 

Sii'^ciO^'i to the W'j/nans Hospital, Xeic York, etc. 

The Principles and Practice of Gynaecology ; For the use of Students and 

Practitioners of Medicine. Second edition. Thoroughly revised. In one large and very 
handsome octavo volume of 879 pages, with 133 illustrations. Cloth, $5.00 ; leather, $6.00 ; 
very handsome half Eussia, $6.50. 

No gynEecologieal treatise has appeared which ' ceived more attention than in America. It is, 

coDTainis an equal amount of original and useful then, with a feeling of pleasure that we w-eleome a 

matter : nor does the medical and surgical history work on diseases of women from so eminent a 

of America include a book more novel and useful, gynsecologist as Dr. Emmet. The work is essen- 

The tabular and statistical information which it tially clinical, and leaves a strong impress of the 

contains is marvellous, both in quantity and accu- authors individuality. To criticise, with the care 

racy, and cannot be otherwise than invaluable to it merits, the book throughout, would demand far 

futiire investigators. It is a work which demands more space than is at our command. In parting, 

not careless reading but profound study. Its value we can say that the work teems with original 

as a contribution to gynsecology is. perhaps, ideas, fresh and valuable methods of practice, and 

greater than that of all previous literature on the is written in a clear and elegant style, worthy of 

subject combined. — Chicago Medical Gazette, A^r]l theliteraryreputationof the country of Longfellow 

5, ISsO. and Oliver Wendell Holmes. — BritishMed, JourncU, 

In no country of the world has gynjecology re- Feb. 21, ISSO. 



DZJ^CAJT, J. JIATTHZWS, JZZ)., ZZ. Z)., F. B. S. Z., etc. 

Clinical Lectui'es on the Diseases of "Women : Delivered in Saint Bar- 
tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. 

They are in every way Trortr.y of their author ; stamp of individuality that, if widely read, as they 
indee.x, we look upon them as anicng the most certamly deserve to be, they cannot' fail to exert a 
valuable of his contributions. They are all upon : wholesome restraint upon' the undue eagerness 
matters of great interest to the general practitioner. \ with which many young physicians seem bent 



Some of them deal ^vith subjects that are not, as a 
rule, adequately handled in 'the text-books : others 
of them, while "bearing uix)n topics that are usually 
treated of at length in such works, yet bear such "a 



upon following the wild teachings which so infest 
the gynsBCology of the present day. — .V. Y. Medical 
Journal, Marcii, ISSO. 



arsszztow, a., 

Fi-cj'i^sor of Midicifery and the Diseases of Children at the Universitv of Berlin, 

A Pi'actical Treatise on Uterine Tuniors. Specially revised by the Author, 
and tninslated with notes and additions by EDAir^n) C. "^Vzxdt, M. D., Pathologist to the 
St. Francis Hospital, ZS . Y., etc., and revised by Xathan Bozemax, M. D., Surgeon to the 
Woman's Hospital of the State of ZSTew York. In one handsome octavo voliune, with about 
40 illustrations. Preparing. 



zroz)Gz:, jetcgmz., jt. i>.. 

Emeritus Professor of Oistetrics, etc., in the JJnitersity of Pennsylvania. 
On Diseases Peculiai' to Women; Including Displacements of the Uterus. 
Second edition, revised and enlarged. In one beautifully printed octavo volume of 519 
pages, with original illustrations. Cloth, $4.50. 



By the Same Author. — 

The Principles and Practice of Obstetrics. Illustrated with lai;ge litho- 
graphic plates containing 159 figures from original photographs, and with numerous wood- 
cuts. In one large quarto volume of 542 double-columned pages. Stronglv boimd in 
cloth, .^14.00. 

■^ ^ ■^ Specimens of the plates and letter-press will be forwarded to any address, free by 
mail, on receipt of six cents in postage stamps. 



TABXZZB, S., and CS[AXTBZ:rZZ, G. 

A Treatise on the Art of Obstetl'ics. Translated from the French. In 
two large octavo volumes, richlv illustrated. 



BAJISBOTZCAJZ, BBAJS^CZS ZT., JtZ. Z). 

The Principles and Practice of Obstetric Medicine and Surgery; 
In reference to the Process of Parturitic'U. A new and enlarged edition, thoroughly revised 
by the Author. With additions by W. V. KiiA.Trs"G, M. D., Professor of Obstetrics, etc., 
in the Jefierson Medical College of Philadelphia. In one large and handsome imi>erial 
octavo volume of 640 pages, with 64 full-page plat^ and 43 woodcuts in the text, contain- 
ing in all nearly 200 beautiful figures. Strongly bound in leather, with raised bands, $7. 



ASHWELL'S PRACTICAL TREATISE 0^' THE AXD OTHER DISEASES PECULIAR TO WO- 

DISEASES PECULIAR TO WOMEN. Third MEX In one 8to. toL of 4^ pages. Cloth, «2.50. 

American from the third and revised London "\ieIG'=J OX THE X\TURE .'^^IGX^ IN'D TREIT- 

edition. In one 8vo. vol., pp. .520. Cloth. ^..50. * MEXT OF CHILDBED FEVER." 'in one^Svo. 

CHURCHILL ON' THE PUERPERAL FEVER Tolume of ai6 pages. Cloth, §2.00. 



Henry C. Lea's Son & jcations— Midwifery. 29 



JPLAYFAIM, W. S., M. 1 C. JP., 

Professor of Obstetric Medicine in King's etc. 

A Treatise on the Science and ^ Midwifery. Third American 

edition, revised by the Author. Edited, \ ' i-: ^ r^^, by Robert P. Harels, M. D. 

In one handsome octavo volume of 659 pag. wii^i 183 : lustrations. Cloth, |4; leather, 
$5 ; half Eussia, $5.50. 

The medical profession has now the opportunity I ' . \ecessary for a full understanding 

of adding to their stock of standard medical works c : ■ ■ are omitted.— Cincinnati Meaical 

one of the best volumes on midwifery ever pub- i\ , ^oHO. 

lished. The subject is taken up with a master ^itainly is an admirable exposition of the 



hand. The part devoted to labor in all its various 
presentations, the management and results, is ad- 
mirably arranged, and the views entertained will 
be found essentially modern, and the opinions ex- 
pressed trustworthy. The work abounds with 
plates, illustrating various obstetrical positions; 
they are admirably wrought, and afford great 
assistance to the student.— iV. 0. Medical and Sur- 
gical Journal, March, 1880. 

If inquired of by a medical student what work 
on obstetrics we should recommend for him, par 
excellence, we would undoubtedly advise him to 
choose Playfair's. It is of convenient size, but 
what is of chief importance, its treatment of the 
various subjects is concise and plain. While the 
discussions and descriptions are sufficiently elabo- 
rate to render a very intelligible idea of them, yet 



science and practice of midwifery. Of course the 
additions made by the "American editor, Dr. R, P. 
Harris, who never utters an idle word, and whose 
studious researches in some special departments 
of obstetrics are so well known to the profession, 
are of great value. — The American Practitioner, 
April, 1880. 

The third edition— so soon following the second — 
shows that the good qualities of the book have been 
recognized by the profession. The second Ameri- 
can has been exhausted before the second English 
edition, and this is therefore especially prepared 
and revised by the author for this country ; a fact 
which ought to be satisfactory as to the profession 
hei-e being furnished with the latest work upon all 
subjects pertaining to obstetrics. — Am. Journal of 
Med. Sciences, April, 1880. 



KIJSTG, A. :F. a., M. D., 

Professor of Obstetrics and Diseases of Women m the Medical Department of the Columbian Univer- 
• sity, Washington, D. C, and in the University of Vermont, etc. 

A Manual of Obstetrics. New edition. In one very handsome 12mo. volume 
of 331 pages, with 59 illustrations. Cloth, $2.00. Just ready. 
A notice of the previous edition is appended. 

lent obstetric dictionary, and well suited to the stu- 



Though the book appears small externally, it 
contains as complete a consideration of obstetric 
subjects as many larger volumes, and this is 
chiefly owing to a directness of expression, and an 
avoidance of repetition and of waste of words. 
The author endeavors to place theories, causes of 
disease and methods of treatment in that order 
which, by weight of authority, they merit. His 
excellent judgment has availed him well in this 
effort. While, in one sense, the book is an excel- 



dent, it is also of value to the general practitioner, 
who often desires to find a resume of information 
upon a given subject. It will be of further value 
to the latter, as, in our opinion, the author holds 
most sensible views on practical matters. The 
book is admirably arranged for reference, being 
well paragraphed, with suitable sub-divisions, and 
well indexed. — American Journal of Obstetrics, Aug. 
1882. 



JPAnVIW, TMJEOJPMILUS, M. JD., LL. D., 

Professor of Obstetrics and the Diseases of Women and Children in the Jeferson Medical College. 

A Treatise on Midwifery. In one very handsome octavo volume of about 550 
pages, with numerous illustrations. In press. 

BAIUS-BS, MOBBMT, M. JD., and FAJSTCOJIBT, 31. JO., 

Phys. to the General Lying-in Hosp., Land. Obstetric Phys. to St. Thotnas' Hasp., Loivi. 

A System of Obstetric Medicine and Surgery, Theoretical and Clin- 
ical. For the Student and the Practitioner. The Section on Embryology contributed by 
Prof. Milnes Marshall. In two handsome octavo volumes, profusely illustrated. In press. 

BAMNBS, JFAJSrCOUMT, II. D., 

Obstetric Physician to St. Thomas' Hospital, London. 

A Manual of Midwifery for Midwives and Medical Students. In one 
royal 12mo. volume of 197 pages, with 50 illustrations. Cloth, $1.25. 

JPAMBT, JOHW S., 31. D., 

Obstetrician to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia. 

Extra - Uterine Pregnancy: Its Clinical History, Diagnosis, Prognosis and 
Treatment. In one handsome octavo volume of 272 pages. Cloth, $2.50. 

TA.WWEH, TII03IAS HAWKJES, 31. D. 

On the Signs and Diseases of Pregnancy. First Amovioan iVom the second 
English edition. In one handsome octavo volume of 490 pages, with 4 colored phites and 
16 woodcuts. Cloth, $4.25. 



WIKCKBL, F. 

A Complete Treatise on the Pathology and Treatment of Childbed. 

For Students and Practitioners. Translated, witii the consent of the Author, from the 
second German edition, bv jAaiES Kead Chadwick, M. 1). In one octavo volume of 484 
pages. Cloth, $4.00. 



30 Henry C. Lea's Son & Co.'s Publications — ^Midwfy., Dis. Childn. 



LJEISSMAJS^, WILLIAM, M. D., 

Regius Professor of Midwifery in the University of Glasgow, etc. 

A System of Midwifery, Including the Diseases of Pregnancy and the 
Puerperal State. Third American edition, revised by the Author, with additions by 
John S. Parry, M. D,, Obstetrician to the Philadelphia Hospital, etc. In one large and 
very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50 ; leather, 
$5.50 ; very handsome half Russia, raised bands, $6.00. 
The author is broad in his teachings, and dis- ! preparation of the present edition the author has 



cusses briefly the comparative anatomy of the pel- 
vis and the mobility of the pelvic articulations. 
The second chapter is devoted especially to 
the study of the pelvis, while in the third the 
female organs of generation are introduced. 
The structure and development of the ovum are 
admirably described. Then follow chapters upon 
the various subjects embraced in the study of mid- 
wifery. The descriptions throughout the work are 
plain and pleasing. It is sufficient to state that in 
this, the last edition of this well-known work, every 
recent advancement in this field has been brought 
forward. — Physician and Surgeon, Jan. 1880. 

We gladly welcome the new edition of this ex- 
cellent text-book of midwifery. The former edi- 
tions have been most favorably received by the 
profession on both sides of the Atlantic. In the 



made such alterations as the progress of obstetri- 
cal science seems to require, and we cannot but 
admire the ability with which the task has been 

Eerformed. We consider it an admirable text- 
ook for students during their attendance upon 
lectures, and have great pleasure in recommend- 
ing it. As an exponent of the midwifery of the 
present day it has no superior in the English lan- 
guage. — Canada Lancet, Jan. 1880. 

To the American student the work before us 
must prove admirably adapted. Complete in all its 
parts, essentially modern in its teachings, and with 
demonstrations noted for clearness and precision, 
it will gain in favor and be recognized as a work 
of standard merit. The work cannot fail to be 
popular and is cordially recommended. — N. 0. 
Med. and Surg. Journ., March, 1880. 



SMITH, J. LEWIS, M. D., 

Clinical Professor of Diseases of Cliildren in the Bellevue Hospital Medical College, N. J. 

A Complete Practical Treatise on the Diseases of Children. Fifth 

edition, thoroughly revised and rewritten. In one handsome octavo volume of 836 pages, 
with illustrations. Cloth, $4.50 ; leather, $5.50 ; very handsome half Russia, raised bands, $6. 

This is one of the best books on the subject with 1 tioners on such questions as etiology, pathology, 
which we have met and one that has given us I prognosis, etc., he has devoted more attention to 
satisfaction on every occasion on which we have j the diagnosis and treatment of the ailments which 
consulted it, either as to diagnosis or treatment. ] he so accurately describes ; and such information 
It is now in its fifth edition and in its present form t is exactly what is wanted by the vast majority of 
is a verv adequate representation of tlie subject it j '"family physicians." — Va. 3Ied. Moiithly, Feb. 1SS2. 

.o+c ^-f „o o+ ,.voo^^+ „r.^o,.e+^^^ ^h^ ,■r..r^^.f or. f I m^ ^ plcasurc to pcrusc such a work as the one 



treats of as at present understood. The important 
subject of infant hygiene is fully dealt with in the 
early portion of the Dook. The great bulk of the 
work is appropriately devoted to the diseases of 
infancy and childhood. We would recommend 
any one in need of information on the subject to 
procure the work and form his own opinion on it, 
which we venture to say will be a favorable one. — 
Dublin Journal of Medical Science, March, 1883. 

There is no book published on the subjects of 
which this one treats that is its equal in value to 
the physician. While he has said just enough to 
impart the information desired by general practi- 



before us, and as reviewers we have but one diffi- 
culty—there is but little to find fault with. The 
author understands what he writes about from a 
practical acquaintance with the diseases incident 
to infancy and childhood, and also thoroughly 
comprehends their pathology and therapeutics. 
The work is full of original and practical remarks 
which will be particularly acceptable to the student 
and young physician ; but at the same time we can 
with great sincerity commend it to the notice of 
the profession in general. — Edinb.Med. Jl., May, '82. 



KBATIWa, jrOMJSTM., M. I)., 

Lecturer on the Diseases of Children at the University of Pennsylvania, etc. 

The Mother^s Guide in the Management and Feeding of Infants. 

one handsome 12mo. volume of 118 pages. Cloth, $1.00. 



In 



Works like this one will aid the physician im- 
mensely, for it saves the time he is constantly giv- 
ing his patients in instructing them on the sub- 
jects here dwelt upon so thoroughly and prac- 
tically. Dr. Keating has written a practical book, 
has carefully avoided unnecessary repetition, and 
successfully instructed the mother in such details 
of the treatment of her child as devolve upon her. 
He has studiously omitted giving prescriptions, 
and instructs the mother when to call upon the 
doctor, as his duties are totally distinct from hers. 
— American Journal of Obstetrics, October, 1881. 

Dr. Keating has kept clear of the common fault 
of works of this sort, viz., mixing the duties of 
the mother with those proper to the doctor. There 
is the ring of common sense in the remarks about 



the employment of a wet-nurse, about the proper 
food for a nursing mother, about the tonic effects 
of a bath, about the perambulator versus the nurses' 
arms, and on many other subjects concerning 
which the critic might say, "surely this is obvi- 
ous," but which experience teaches us are exactly 
the things needed to be insisted upon, with the rich 
as well as the poor. — London Lancet, January, 28 1882. 
A book small in size, written in pleasant style, in 
language whi ch can be readily understood by any 
mother, and eminently practical and safe; in fact 
a book for which we have been waiting a long 
time, and which we can most heartily recommend 
to mothers as the book on this subject. — JVew York 
Medical Journal and Obstetrical Eeview, Feb. 1882. 



WLST, CJaCAHLLS, M. D., 

Physician to the Hospital for Sick Children, London, etc. 

Lectures on the Diseases of Infancy and Childhood. Fifth American 
from the sixth revi^ and enlarged English edition. In one large and handsome octavo 
volume of 686 page . Cloth, $4.50 ; leather, $5.50. 



By the Same Author. 

On Some Disorders of the Nervous System in Childhood. 

12mo. volume of 127 pages. Cloixi, $1.00. 



In one small 



CONDIE'S PRACTICAL TREATISE ON THE 
DISEASES OF CHILDREN. Sixth edition, re- 



vised and augmented. In one octavo volume oJ 
779 pages. Cloth, $5.25 ; leather, $6.25. 



HENRir C. Lea's Son & Co.'s Publications — Med. Juris., Miscel. 31 



TinY, CSAMLBS MBYMOTT, M. B., F. C. S., 

Professor of Chemistry and oj Forensic Medicine and Public Health at the London Hospital, etc. 

Legal Medicine. Volume II. Legitimacy and Paternity, Pregnancy, Abor- 
tion, Kape, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide, Asphyxia, 
Drowning, Hanging, Strangulation, Suffocation. Making a very handsome imperial oc- 
tavo volume of 529 pages. Cloth, $6.00; leather, $7.00. Just ready. 

Volume L Containing 664 imperial octavo pages, with two beautiful colored 
plates. Cloth, $6.00 ; leather, $7.00. Recently issued. 

He whose inclinations or necessities lead him to The fact that the v6ry numerous illustrative cases 
assume the functions of a medical jurist wants a are drawn from many sources, and are not limited, 
book encyclopsedic in character, in which he may as in Casper's Handbook, to the author's own ex- 
be reasonablv sure of finding medico-legal topics perience, and the additional fact that they are 
discussed wih judicial fairness, with sufficient brought down to a very recent date, give them, 
completeness, and with due attention to the most for purposes of reference, a very obvious value.— 
recent advances in medical science. Mr. Tidy's Boston Medical and Surgical Journal, Feb. 8, 1883. 
work bids fair to meet this need satisfactorily. 



TAYLOM, ALFUBD S., M. D., 

Lecturer on Medical Jurisprudence and Chemistry in Cruy''s Hospital, London. 

A Manual of Medical Jurisprudence. Eighth American from the tenth Lon- 
don edition, thoroughly revised and rewritten. Edited by John J. Reese, M. D., Professor 
of Medical Jurisprudence and Toxicology in the University of Pennsylvania. In one 
large octavo volume of 937 pages, with 70 illustrations. Cloth, $5.00 ; leather, $6.00 ; half 
Russia, raised bands, $6.50. 



The American editions of this standard manual 
have for a long time laid claim to the attention of 
the profession in this country; and the eighth 
comes before us as embodying the latest thoughts 
and emendations of Dr. Taylor upon the subject 
to which he devoted his life with an assiduity and 
success which made him facile princeps among 
English writers on medical jurisprudence. Both 
the author and the book have made a mark too 
deep to be affected by criticism, whether it be 
censure or praise. In this case, however, we should 



only have to seek for landatory terms. — American 
Journal of the Medical Sciences, Jan. 1881. 

This celebrated work has been the standard au- 
thority in its department for thirty-seven years, 
both in England and America, in both the profes- 
sions which it concerns, and it is improbable that 
it will be superseded in many years. The work is 
simply indispensable to every physician, and nearly 
so to every liberally-educated lawyer, and we 
heartily commend the present edition to both pro- 
fessions. — Albany Law Journal, March 26, 1881. 



By the Same Author. 

The Principles and Practice of Medical Jurisprudence. Third edition. 
In two handsome octavo volumes, containing 1416 pages, with 188 illustrations. Cloth, $10 ; 
leather, $12. Just ready. 

The revision of the third edition of this standard work has been most happily con- 
fided to a gentleman who was during fourteen years the colleague of the author, and who 
therefore is thoroughly conversant with the methods of thought which have everywhere 
gained for the book an exalted position as a work of reference. In its present form the 
work is the most complete exposition of Forensic Medicine in the English language. 

Taylor's Treatise at the hands of Dr. Stevenson books of its class. Including within its purview, 

has undergone a diminution of bulk with an in- as the subject does, something from every divi- 

crease of mass. This edition only asserts with sion of medical science, this exhaustive treatise 

stronger reason the allowed claims of the late Dr. will ever remain an invaluable collection of data. 

Taylor's work to the first position among English — New York Medical Journal, Dec. 1, 1SS3. 



By the Same Author. 
Poisons in Relation to Medical Jurisprudence and Medicine. Third 
American, from the third and revised English edition. In one large octavo volume of 788 
pages. Cloth, $5.50 ; leather, $6.50. 

LFA, HENBY C. 

Superstition and Force : Essays on The Wager of Law, The Wager of 
Battle, The Ordeal and Torture. Third revised and enlarged edition. In one 

Cloth, $2.50. 

should not be most carefully studied ; and however 
well versed the reader may be in the science of 
jurisprudence, he will find much in JMr. Lea's vol- 
ume of whicli ho was previouslj' ignonuit. The 
book is a valuable addition to the literature of so- 
cial science. — Westminster Bcview, Jan. ISSO. 



handsome royal 12mo. volume of 552 pages. 
This valuable work is in reality a historj' of civ- 
ilization as interpreted by the progress of jurispru- 
denoe. . . In "Superstition and Force" we have a 
philosophic survey of the long period intervening 
between primitive barbarity and civilized enlight- 
enment. There is not a chapter in the work that 



By the Same Author. 
Studies in Church History. The Rise of the Temporal Power- 



eflt of Clergy — Excommunication, 
octavo volume of 005 pages. Cloth, $2.50. 

Th(> author is pre-eminently a scholar. He takOvS 
up every topic allied with the leading theme, and 
traces it out to the minutest detail with a woaltli 
of knowledge and impartialilv of treatment tliat 
compel admiration. Tho amount of information 
compressed into the book is extraordiuarv. In no 
other single volume is the development of tho 



-Ben- 



New edition. In one very handsome royal 

Just ready. 

primitive church traced with so much cloarness, 
and with so definite a perception of complex or 
contlicting sources. Tiio fifty pages on the growth 
of tho papacv, for instance, are jidnurable for cou- 
ciscnoss ancl freedom from prejudice. — Boston 
Traveller, May 3. 1SS3. 



32 Henry C. Lea's Son & Co.'s Medical and Surgical Publications. 



INDEX TO CATALOGUE. 



American Journal of the Medical Sciences 

American System of Gynaecology . 

Allen's Anatomy .... 

*Asliliurst's Surgery .... 

Ashwell on Diseases of Women 

Attfield's Chemistry .... 

Barlow's Practice of Medicine 

Barnes' Midwifery .... 

*Barnes on Diseases of Women 

Barnes' System of Obstetric Medicine 

Bartholow on Electricity 

Basham on Renal Diseases . 

Bell's Comparative Physiology and Anatomy 

Bellamy's Operative Surgery 

Bellamy's Surgical Anatomy 

Blandford on Insanity 

Bloxam's Chemistry .... 

Bowman's Practical Chemistry 

*Bristowe's Practice of Medicme . 

Browne on the Ophthalmoscope . 

Browne on the Throat 

Bruce's Materia Medica and Therapeutics 

Brunton's Materia Medica and Therapeutics 

*Bryant's Practice of Surgery 

*Bumstead on Venereal Diseases . 

*Burnett on the Ear .... 

Carpenter on the Use and Abuse of Alcohol 

*Carpenter"s Human Physiology . 

Carter on the Eye .... 

Century of American Medicme 

Chadwick on Diseases of Women . 

Chambers on Diet and Regimen . 

Churchill on Puerperal Fever 

Clarke and Lockwood's Dissectors' Manual 

Classen's Quantitative Analysis 

Cleland's Dissector .... 

Clouston on Insanity .... 

Clowes' Practical Chemistry 

Coats' Pathology .... 

Coleman's Dental Surgery . 

Condie on Diseases of Children 

Cooper's Lectures on Surgery 

*Cornil and Ranvier's Pathological Histology 

Cornil on Syphilis .... 

Cullerier's Atlas of Venereal Diseases 

*Dalton's Human Physiology 

Dalton's Topographical Anatomy of the Brain 

Davis' Clinical Lectures 

Driiitt's Modern Surgery 

Dujardin-Beaumetz"s Dict'y of Therapeutics 

Duncan on Diseases of Women 

*Dunglison's Medical Dictionary . 

Edison Diseases of Women . 

Ellis' Demonstrations of Anatomy 

*Emmet's Gyntecologv 

*Erichsen's System of Surgery 

Esmarch's Early Aid in Injuries and Accid'ts 

Farquharson's Therapeutics and Mat. Med. 

Fenwick's Medical Diagnosis 

Finlayson's Clinical Diagnosis 

Fliut on Auscultation and Percussion 

Flint on Phthisis .... 

Flint on Physical Exploration of the Lungs 

Flint on Respiratory Organs 

Flint on the Heart .... 

*Flint's Clinical Medicine 

Flint's Essays . . . . ' 

^Flint's Practice of Medicine 

Foster's Physiology .... 

*Fothergiirs Handbook of Treatment . 

Fownes' Elementary Chemistry . 

Fox on Diseases of the Skin . 

Fuller on the Lungs and Air Passages . 

Galloway's Analysis .... 

Gibney's Orthopsedic Surgery 

Gibson's Surgery . . ... 

Gluge's Pathological Histology, by Leidy 

*Grav's Anatomy ..... 

Greene's Medical Chemistry . 

Green's Pathology and Morbid Anatomy 

Griffith's Universal Formulary 

Gross on Foreign Bodies in Air-Passages 

Gross on Impotence and Sterility . 

Gross on Urinary Organs 

*Gross' System of Surgery . 

Gusserow on Uterine Tumors 

Gynecological Transactions . 

Habershon on the Abdomen 

^Hamilton on Fractures and Dislocations 

Hamilton on Nervous Diseases 

Hartshorne's Anatomy and Physiology . 

Kartshorne's Conspectus of the Med. Sciences 

Hartshorne's Essentials of Medicine 

Hermann's Experimental Pharmacology 

Hill on Svv>hi]is ..... 

Hillier's Handbook of Skin Diseases 



PAGE. 
2 

27 



Hoblyn's Medical Dictionary 

Hodge on Women .... 

Hodge's Obstetrics .... 

Homnann and Power's Chemical Analysis 

Holden's Landmarks .... 

Holland's Medical Notes and Reflections 

^Holmes' System of Surgery 

Horner's Anatomy and Histology 

Hudson on Fever . . . . . 

Hyde on the Diseases of the Skin . 

Jones (C. Handfield) on Nervous Disorders 

Keating on Infants .... 

King's Manual of Obstetrics . 

Klein's Histology .... 

La Roche on Pneumonia, Malaria, etc. . 

La Roche on Yellow Fever . 

Laureuce and Moon's Ophthalmic Surgery 

Lawson on the Eye, Orbit and Eyelid 

Lea's Studies in Church History 

Lea's Superstition and Force 

Lee on Syphilis ..... 

Lehmanu's Chemical Physiology . 

*Leishman's Midwifery 

Ludlow's Manual of Examinations 

Lyons on Fever ..... 

Maisch's Organic Materia Medica . 

Medical News ..... 

Meigs on Childbed Fever 

Miller's Practice of Surgery . 

Millers Principles of Surgery 

Mitcheil's Nervous Diseases of Women . 

Morris on Skin Diseases 

Neill and Smith's Compendium of Med. Sci. 

Nettleship on Diseases of the Eye . 

*Parrish's Practical Pharmacy 

Parry on Extra-Uterine Pregnancy 

Parvin's Midwifery .... 

Pavy on Digestion and its Disorders 

Pepper's Surgical Pathology 

Piri-ie's System of Surgery 

Playfair on Nerve Prostration and Hysteria 

*Playfair's Midwifery .... 

Politzer on the Ear and its Diseases 

Power's Human Physiology . 

Ralfe's Clinical Chemistry 

Ramsbotham on Parturition 

Remsen's Theoretical Chemistry . 

^Reynolds' System of Medicine 

Richardson's'Preventive Medicine 

Roberts on Urinary Diseases 

Roberts' Principles and Practice of Surgery 

Robertson's Physical Physiology . 

Rodwell's Dictionary of Science 

Sargent's Minor and Military Surgery . 

Schafer's Histology .... 

Seller on the Throat, Nose and Naso-Pharynx 

Skey's Operative Surgery 

Slade on Diphtheria .... 

Smith (Edward) on Consumption . 

Smith (H. H.) and Horner's Anatomical Atlas 

*Smith (J. Lewis) on Children 

*Stille & Maisch's National Dispensatory 

*Stilh-;'s Therapeutics and Materia Medica 

Stimson on Fractures .... 

Stimson's Operative Surgery 

Stokes on Fever ..... 

Students' Series of Manuals . 

Sturges' Clinical Medicine 

Tanner on Signs and Diseases of Pregnancy 

Tanner's Manual of Clinical Medicine . 

Tarnier and Chantreuil's Obstetrics 

Taylor on Poisons .... 

*Tavlor's Medical Jurisprudence . 

Taylor's Prin. and Prac. of Med. Jurisprudence 

*Thomas on Diseases of Women . 

Thompson on Stricture 

Thompson on Urinary Organs 

Tidy's Legal Medicine .... 

Todd on Acute Diseases 

Treves' Applied Anatomy 

Tuke on the Influence of Mind on the Body 

Walshe on the Heart .... 

Watson's Practice of Physic . 

Watts' Physical and Inorganic Chemistry 

* Wells on'ihe Eye .... 

West on Diseases of Childhood 

West on Diseases of Women 

West on Nervous Disorders in Childhood 

Williams on Consumption . 

Wilson's Handbook of Cutaneous Medicine 

Wilson's Human Anatomv . 

Winckel on Pathol, and Treatment of Childbed 

AVohler's Organic Chemistry 

Woodbury's Practice of Medicine . 

Woodhea'd's Practical Pathology . 



PAGE. 
4 



Books marked * are also bound in half Eussia. 



""'^i^^,^ 



HENKY C. LEA'S SON & CO., 
Philadelpliia. 



